hospital_name,last_updated_on,version,hospital_location,hospital_address,license_number|LA,"To the best of its knowledge and belief, the hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date indicated.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Reeves Memorial Medical Center,12/18/2024,2.0.0,Reeves Memorial Medical Center,"409 1st Street Bernice, LA 71222",720685207,TRUE,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
description,code|1,code|1|type,code|2,code|2|type,code|3,code|3|type,setting,drug_unit_of_measurement,drug_type_of_measurement,standard_charge|gross,standard_charge|discounted_cash,modifiers,standard_charge|AETNA|COMMERCIAL|negotiated_dollar,standard_charge|AETNA|COMMERCIAL|negotiated_percentage,standard_charge|AETNA|COMMERCIAL|negotiated_algorithm,estimated_amount|AETNA|COMMERCIAL,standard_charge|AETNA|COMMERCIAL|methodology,additional_payer_notes|AETNA|COMMERCIAL,standard_charge|BCBS ADVANTAGE|MEDICARE|negotiated_dollar,standard_charge|BCBS ADVANTAGE|MEDICARE|negotiated_percentage,standard_charge|BCBS ADVANTAGE|MEDICARE|negotiated_algorithm,estimated_amount|BCBS ADVANTAGE|MEDICARE,standard_charge|BCBS ADVANTAGE|MEDICARE|methodology,additional_payer_notes|BCBS ADVANTAGE|MEDICARE,standard_charge|BCBS HMO|COMMERCIAL|negotiated_dollar,standard_charge|BCBS HMO|COMMERCIAL|negotiated_percentage,standard_charge|BCBS HMO|COMMERCIAL|negotiated_algorithm,estimated_amount|BCBS HMO|COMMERCIAL,standard_charge|BCBS HMO|COMMERCIAL|methodology,additional_payer_notes|BCBS HMO|COMMERCIAL,standard_charge|BCBS PPO|COMMERCIAL|negotiated_dollar,standard_charge|BCBS PPO|COMMERCIAL|negotiated_percentage,standard_charge|BCBS PPO|COMMERCIAL|negotiated_algorithm,estimated_amount|BCBS PPO|COMMERCIAL,standard_charge|BCBS PPO|COMMERCIAL|methodology,additional_payer_notes|BCBS PPO|COMMERCIAL,standard_charge|BCBS TRADITIONAL|COMMERCIAL|negotiated_dollar,standard_charge|BCBS TRADITIONAL|COMMERCIAL|negotiated_percentage,standard_charge|BCBS TRADITIONAL|COMMERCIAL|negotiated_algorithm,estimated_amount|BCBS TRADITIONAL|COMMERCIAL,standard_charge|BCBS TRADITIONAL|COMMERCIAL|methodology,additional_payer_notes|BCBS TRADITIONAL|COMMERCIAL,standard_charge|CIGNA|COMMERCIAL|negotiated_dollar,standard_charge|CIGNA|COMMERCIAL|negotiated_percentage,standard_charge|CIGNA|COMMERCIAL|negotiated_algorithm,estimated_amount|CIGNA|COMMERCIAL,standard_charge|CIGNA|COMMERCIAL|methodology,additional_payer_notes|CIGNA|COMMERCIAL,standard_charge|HUMANA HMO|MEDICARE|negotiated_dollar,standard_charge|HUMANA HMO|MEDICARE|negotiated_percentage,standard_charge|HUMANA HMO|MEDICARE|negotiated_algorithm,estimated_amount|HUMANA HMO|MEDICARE,standard_charge|HUMANA HMO|MEDICARE|methodology,additional_payer_notes|HUMANA HMO|MEDICARE,standard_charge|HUMANA MEDICARE HMO|MEDICARE|negotiated_dollar,standard_charge|HUMANA MEDICARE HMO|MEDICARE|negotiated_percentage,standard_charge|HUMANA MEDICARE HMO|MEDICARE|negotiated_algorithm,estimated_amount|HUMANA MEDICARE HMO|MEDICARE,standard_charge|HUMANA MEDICARE HMO|MEDICARE|methodology,additional_payer_notes|HUMANA MEDICARE HMO|MEDICARE,standard_charge|HUMANA MEDICARE PFFS|MEDICARE|negotiated_dollar,standard_charge|HUMANA MEDICARE PFFS|MEDICARE|negotiated_percentage,standard_charge|HUMANA MEDICARE PFFS|MEDICARE|negotiated_algorithm,estimated_amount|HUMANA MEDICARE PFFS|MEDICARE,standard_charge|HUMANA MEDICARE PFFS|MEDICARE|methodology,additional_payer_notes|HUMANA MEDICARE PFFS|MEDICARE,standard_charge|HUMANA MEDICARE PPO|MEDICARE|negotiated_dollar,standard_charge|HUMANA MEDICARE PPO|MEDICARE|negotiated_percentage,standard_charge|HUMANA MEDICARE PPO|MEDICARE|negotiated_algorithm,estimated_amount|HUMANA MEDICARE PPO|MEDICARE,standard_charge|HUMANA MEDICARE PPO|MEDICARE|methodology,additional_payer_notes|HUMANA MEDICARE PPO|MEDICARE,standard_charge|HUMANA POS|MEDICARE|negotiated_dollar,standard_charge|HUMANA POS|MEDICARE|negotiated_percentage,standard_charge|HUMANA POS|MEDICARE|negotiated_algorithm,estimated_amount|HUMANA POS|MEDICARE,standard_charge|HUMANA POS|MEDICARE|methodology,additional_payer_notes|HUMANA POS|MEDICARE,standard_charge|HUMANA PPO|MEDICARE|negotiated_dollar,standard_charge|HUMANA PPO|MEDICARE|negotiated_percentage,standard_charge|HUMANA PPO|MEDICARE|negotiated_algorithm,estimated_amount|HUMANA PPO|MEDICARE,standard_charge|HUMANA PPO|MEDICARE|methodology,additional_payer_notes|HUMANA PPO|MEDICARE,standard_charge|VANTAGE|COMMERCIAL|negotiated_dollar,standard_charge|VANTAGE|COMMERCIAL|negotiated_percentage,standard_charge|VANTAGE|COMMERCIAL|negotiated_algorithm,estimated_amount|VANTAGE|COMMERCIAL,standard_charge|VANTAGE|COMMERCIAL|methodology,additional_payer_notes|VANTAGE|COMMERCIAL,standard_charge|VANTAGE|MEDICARE|negotiated_dollar,standard_charge|VANTAGE|MEDICARE|negotiated_percentage,standard_charge|VANTAGE|MEDICARE|negotiated_algorithm,estimated_amount|VANTAGE|MEDICARE,standard_charge|VANTAGE|MEDICARE|methodology,additional_payer_notes|VANTAGE|MEDICARE,standard_charge|VANTAGE PPO|MEDICARE|negotiated_dollar,standard_charge|VANTAGE PPO|MEDICARE|negotiated_percentage,standard_charge|VANTAGE PPO|MEDICARE|negotiated_algorithm,estimated_amount|VANTAGE PPO|MEDICARE,standard_charge|VANTAGE PPO|MEDICARE|methodology,additional_payer_notes|VANTAGE PPO|MEDICARE,standard_charge|min,standard_charge|max,additional_generic_notes
PRIVATE ROOM,,,110,RC,,,inpatient,,,900,540.00,,790,100,,,per diem,pays based on per day rate,3650,100,,,per diem,pays based on per day rate,837,93,,669.6,percent of total billed charges,93% of total billed charges ,837,93,,669.6,percent of total billed charges,93% of total billed charges,837,93,,669.6,percent of total billed charges,93% of total billed charges,1025,100,,,per diem ,pays based on per day rate,630,70,,504,percent of total billed charges,70% of total billed charges,3650,100,,,per diem ,pays based on per day rate,3650,100,,,per diem ,pay based on per day rate,3650,100,,,per diem,pays based on per day rate,630,70,,504,percent of total billed charges,70% of total billed charges,630,70,,504,percent of total billed charges,70% of total billed charges,1400,100,,,per diem,pays based on per day rate,1400,100,,,per diem,pays based on per day rate,810,90,,648,percent of total billed charges,90% of total billed charges,90,1400,
CPR INPATIENT,36010117,CDM,410,RC,92950,HCPCS,outpatient,,,820,492.00,,492,60,,393.6,percent of total billed charges,60% of total billed charges,393.6,48,,314.88,percent of total billed charges,48% of total billed charges,399.79,100,,,fee schedule,100% of bcbs custom fee schedule,399.79,100,,,fee schedule,100% of bcbs custom fee schedule,443.77,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,574,70,,459.2,percent of total billed charges,70% of total billed charges,397.54,48.48,,318.032,percent of total billed charges,48.48% of total billed charges,206.55,116.15,,,fee schedule,116.51% of cms physician fee schedule,397.54,48.48,,318.032,percent of total billed charges,48.48% of total billed charges,574,70,,459.2,percent of total billed charges,70% of total billed charges,574,70,,459.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,397.54,48.48,,318.032,percent of total billed charges,48.48% of total billed charges,738,90,,590.4,percent of total billed charges,90% of total billed charges,48.48,738,
BLOOD TRANSFUSION,32000016,CDM,391,RC,36430,HCPCS,outpatient,,,1250,750.00,,399,100,,,fee schedule,100% of asc tier groupings rate,600,48,,480,percent of total billed charges,48% of total billed charges,592.29,100,,,fee schedule,100% of bcbs custom fee schedule,592.29,100,,,fee schedule,100% of bcbs custom fee schedule,657.44,111,,,fee schedule,111% of bcbs custom fee schedule,625,50,,500,percent of total billed charges,50% of total billed charges,875,70,,700,percent of total billed charges,70% of total billed charges,606,48.48,,484.8,percent of total billed charges,48.48% of total billed charges,43.32,116.15,,,fee schedule,116.51% of cms physician fee schedule,606,48.48,,484.8,percent of total billed charges,48.48% of total billed charges,875,70,,700,percent of total billed charges,70% of total billed charges,875,70,,700,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,606,48.48,,484.8,percent of total billed charges,48.48% of total billed charges,1125,90,,900,percent of total billed charges,90% of total billed charges,48.48,1125,
DRESS/DEBRID LG BURN,,,272,RC,,,outpatient,,,225,135.00,,135,60,,108,percent of total billed charges,60% of total billed charges,108,48,,86.4,percent of total billed charges,48% of total billed charges,112.5,50,,90,percent of total billed charges,50% of total billed charges,112.5,50,,90,percent of total billed charges,50% of total billed charges,112.5,50,,90,percent of total billed charges,50% of total billed charges,112.5,50,,90,percent of total billed charges,50% of total billed charges,157.5,70,,126,percent of total billed charges,70% of total billed charges,109.08,48.48,,87.264,percent of total billed charges,48.48% of total billed charges,109.08,48.48,,87.264,percent of total billed charges,48.48% of total billed charges,109.08,48.48,,87.264,percent of total billed charges,48.48% of total billed charges,157.5,70,,126,percent of total billed charges,70% of total billed charges,157.5,70,,126,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,109.08,48.48,,87.264,percent of total billed charges,48.48% of total billed charges,202.5,90,,162,percent of total billed charges,90% of total billed charges,48.48,202.5,
IV INFUS SEQ UP TO 1 HR,32009051,CDM,260,RC,96367,HCPCS,outpatient,,,91.25,54.75,,54.75,60,,43.8,percent of total billed charges,60% of total billed charges,43.8,48,,35.04,percent of total billed charges,48% of total billed charges,105.22,100,,,fee schedule,100% of bcbs custom fee schedule,105.22,100,,,fee schedule,100% of bcbs custom fee schedule,116.79,111,,,fee schedule,111% of bcbs custom fee schedule,45.63,50,,36.504,percent of total billed charges,50% of total billed charges,63.88,70,,51.104,percent of total billed charges,70% of total billed charges,44.24,48.48,,35.392,percent of total billed charges,48.48% of total billed charges,29.79,116.15,,,fee schedule,116.51% of cms physician fee schedule,44.24,48.48,,35.392,percent of total billed charges,48.48% of total billed charges,63.88,70,,51.104,percent of total billed charges,70% of total billed charges,63.88,70,,51.104,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,44.24,48.48,,35.392,percent of total billed charges,48.48% of total billed charges,82.13,90,,65.704,percent of total billed charges,90% of total billed charges,44.24,90,
THER/DIAG CONCURRENT INF,32009052,CDM,260,RC,96368,HCPCS,outpatient,,,135,81.00,,81,60,,64.8,percent of total billed charges,60% of total billed charges,64.8,48,,51.84,percent of total billed charges,48% of total billed charges,105.22,100,,,fee schedule,100% of bcbs custom fee schedule,105.22,100,,,fee schedule,100% of bcbs custom fee schedule,116.79,111,,,fee schedule,111% of bcbs custom fee schedule,67.5,50,,54,percent of total billed charges,50% of total billed charges,94.5,70,,75.6,percent of total billed charges,70% of total billed charges,65.45,48.48,,52.36,percent of total billed charges,48.48% of total billed charges,20.9,116.15,,,fee schedule,116.51% of cms physician fee schedule,65.45,48.48,,52.36,percent of total billed charges,48.48% of total billed charges,94.5,70,,75.6,percent of total billed charges,70% of total billed charges,94.5,70,,75.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,65.45,48.48,,52.36,percent of total billed charges,48.48% of total billed charges,121.5,90,,97.2,percent of total billed charges,90% of total billed charges,48.48,121.5,
IV INJECTION EACH NEW SUB,32004012,CDM,260,RC,96375,HCPCS,outpatient,,,135,81.00,,81,60,,64.8,percent of total billed charges,60% of total billed charges,64.8,48,,51.84,percent of total billed charges,48% of total billed charges,57.29,100,,,fee schedule,100% of bcbs custom fee schedule,57.29,100,,,fee schedule,100% of bcbs custom fee schedule,63.59,111,,,fee schedule,111% of bcbs custom fee schedule,67.5,50,,54,percent of total billed charges,50% of total billed charges,94.5,70,,75.6,percent of total billed charges,70% of total billed charges,65.45,48.48,,52.36,percent of total billed charges,48.48% of total billed charges,16.16,116.15,,,fee schedule,116.51% of cms physician fee schedule,65.45,48.48,,52.36,percent of total billed charges,48.48% of total billed charges,94.5,70,,75.6,percent of total billed charges,70% of total billed charges,94.5,70,,75.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,65.45,48.48,,52.36,percent of total billed charges,48.48% of total billed charges,121.5,90,,97.2,percent of total billed charges,90% of total billed charges,48.48,121.5,
IV HYDR 31 MIN-1HR; INTL,32000100,CDM,260,RC,96360,HCPCS,outpatient,,,208.75,125.25,,125.25,60,,100.2,percent of total billed charges,60% of total billed charges,100.2,48,,80.16,percent of total billed charges,48% of total billed charges,133.96,100,,,fee schedule,100% of bcbs custom fee schedule,133.96,100,,,fee schedule,100% of bcbs custom fee schedule,148.7,111,,,fee schedule,111% of bcbs custom fee schedule,104.38,50,,83.504,percent of total billed charges,50% of total billed charges,146.13,70,,116.904,percent of total billed charges,70% of total billed charges,101.2,48.48,,80.96,percent of total billed charges,48.48% of total billed charges,33.76,116.15,,,fee schedule,116.51% of cms physician fee schedule,101.2,48.48,,80.96,percent of total billed charges,48.48% of total billed charges,146.13,70,,116.904,percent of total billed charges,70% of total billed charges,146.13,70,,116.904,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,101.2,48.48,,80.96,percent of total billed charges,48.48% of total billed charges,187.88,90,,150.304,percent of total billed charges,90% of total billed charges,48.48,187.88,
IV HYDRATION EA ADD'L HR,32000101,CDM,260,RC,96361,HCPCS,outpatient,,,45,27.00,,27,60,,21.6,percent of total billed charges,60% of total billed charges,21.6,48,,17.28,percent of total billed charges,48% of total billed charges,43.04,100,,,fee schedule,100% of bcbs custom fee schedule,43.04,100,,,fee schedule,100% of bcbs custom fee schedule,47.77,111,,,fee schedule,111% of bcbs custom fee schedule,22.5,50,,18,percent of total billed charges,50% of total billed charges,31.5,70,,25.2,percent of total billed charges,70% of total billed charges,21.82,48.48,,17.456,percent of total billed charges,48.48% of total billed charges,13.06,116.15,,,fee schedule,116.51% of cms physician fee schedule,21.82,48.48,,17.456,percent of total billed charges,48.48% of total billed charges,31.5,70,,25.2,percent of total billed charges,70% of total billed charges,31.5,70,,25.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,21.82,48.48,,17.456,percent of total billed charges,48.48% of total billed charges,40.5,90,,32.4,percent of total billed charges,90% of total billed charges,21.82,90,
IV INJECTION THERAPEUTIC,32004011,CDM,260,RC,96374,HCPCS,outpatient,,,135,81.00,,81,60,,64.8,percent of total billed charges,60% of total billed charges,64.8,48,,51.84,percent of total billed charges,48% of total billed charges,105.22,100,,,fee schedule,100% of bcbs custom fee schedule,105.22,100,,,fee schedule,100% of bcbs custom fee schedule,116.79,111,,,fee schedule,111% of bcbs custom fee schedule,67.5,50,,54,percent of total billed charges,50% of total billed charges,94.5,70,,75.6,percent of total billed charges,70% of total billed charges,65.45,48.48,,52.36,percent of total billed charges,48.48% of total billed charges,38.32,116.15,,,fee schedule,116.51% of cms physician fee schedule,65.45,48.48,,52.36,percent of total billed charges,48.48% of total billed charges,94.5,70,,75.6,percent of total billed charges,70% of total billed charges,94.5,70,,75.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,65.45,48.48,,52.36,percent of total billed charges,48.48% of total billed charges,121.5,90,,97.2,percent of total billed charges,90% of total billed charges,48.48,121.5,
IV INJECTION ADD SAME SUB,32004015,CDM,260,RC,96376,HCPCS,outpatient,,,87.5,52.50,,52.5,60,,42,percent of total billed charges,60% of total billed charges,42,48,,33.6,percent of total billed charges,48% of total billed charges,1.16,100,,,fee schedule,100% of bcbs custom fee schedule,1.16,100,,,fee schedule,100% of bcbs custom fee schedule,1.29,111,,,fee schedule,111% of bcbs custom fee schedule,43.75,50,,35,percent of total billed charges,50% of total billed charges,61.25,70,,49,percent of total billed charges,70% of total billed charges,42.42,48.48,,33.936,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,42.42,48.48,,33.936,percent of total billed charges,48.48% of total billed charges,61.25,70,,49,percent of total billed charges,70% of total billed charges,61.25,70,,49,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,42.42,48.48,,33.936,percent of total billed charges,48.48% of total billed charges,78.75,90,,63,percent of total billed charges,90% of total billed charges,42.42,90,
INS TEMP BLADDER CATH,36011020,CDM,230,RC,51702,HCPCS,outpatient,,,218.75,131.25,,399,100,,,fee schedule,100% of asc tier groupings rate,105,48,,84,percent of total billed charges,48% of total billed charges,99.81,100,,,fee schedule,100% of bcbs custom fee schedule,99.81,100,,,fee schedule,100% of bcbs custom fee schedule,110.79,111,,,fee schedule,111% of bcbs custom fee schedule,109.38,50,,87.504,percent of total billed charges,50% of total billed charges,153.13,70,,122.504,percent of total billed charges,70% of total billed charges,106.05,48.48,,84.84,percent of total billed charges,48.48% of total billed charges,28.41,116.15,,,fee schedule,116.51% of cms physician fee schedule,106.05,48.48,,84.84,percent of total billed charges,48.48% of total billed charges,153.13,70,,122.504,percent of total billed charges,70% of total billed charges,153.13,70,,122.504,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,106.05,48.48,,84.84,percent of total billed charges,48.48% of total billed charges,196.88,90,,157.504,percent of total billed charges,90% of total billed charges,48.48,196.88,
PNEUMONIA VAC ADMINISTRAT,36009195,CDM,771,RC,G0009,HCPCS,outpatient,,,32,19.20,,19.2,60,,15.36,percent of total billed charges,60% of total billed charges,15.36,48,,12.288,percent of total billed charges,48% of total billed charges,16,50,,12.8,percent of total billed charges,50% of total billed charges,16,50,,12.8,percent of total billed charges,50% of total billed charges,16,50,,12.8,percent of total billed charges,50% of total billed charges,16,50,,12.8,percent of total billed charges,50% of total billed charges,22.4,70,,17.92,percent of total billed charges,70% of total billed charges,15.51,48.48,,12.408,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,15.51,48.48,,12.408,percent of total billed charges,48.48% of total billed charges,22.4,70,,17.92,percent of total billed charges,70% of total billed charges,22.4,70,,17.92,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,15.51,48.48,,12.408,percent of total billed charges,48.48% of total billed charges,28.8,90,,23.04,percent of total billed charges,90% of total billed charges,15.51,90,
IP PLACEMENT NEEDLE INTRAOSSEOUS TISSUE,36011054,CDM,230,RC,36680,HCPCS,outpatient,,,183.8,110.28,,399,100,,,fee schedule,100% of asc tier groupings rate,88.22,48,,70.576,percent of total billed charges,48% of total billed charges,152.16,100,,,fee schedule,100% of bcbs custom fee schedule,152.16,100,,,fee schedule,100% of bcbs custom fee schedule,168.9,111,,,fee schedule,111% of bcbs custom fee schedule,91.9,50,,73.52,percent of total billed charges,50% of total billed charges,128.66,70,,102.928,percent of total billed charges,70% of total billed charges,89.11,48.48,,71.288,percent of total billed charges,48.48% of total billed charges,67.97,116.15,,,fee schedule,116.51% of cms physician fee schedule,89.11,48.48,,71.288,percent of total billed charges,48.48% of total billed charges,128.66,70,,102.928,percent of total billed charges,70% of total billed charges,128.66,70,,102.928,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,89.11,48.48,,71.288,percent of total billed charges,48.48% of total billed charges,165.42,90,,132.336,percent of total billed charges,90% of total billed charges,48.48,165.42,
INTRAOSSEOUS PLACEMENT INPT,36011054,CDM,230,RC,36680,HCPCS,outpatient,,,183.8,110.28,,399,100,,,fee schedule,100% of asc tier groupings rate,88.22,48,,70.576,percent of total billed charges,48% of total billed charges,152.16,100,,,fee schedule,100% of bcbs custom fee schedule,152.16,100,,,fee schedule,100% of bcbs custom fee schedule,168.9,111,,,fee schedule,111% of bcbs custom fee schedule,91.9,50,,73.52,percent of total billed charges,50% of total billed charges,128.66,70,,102.928,percent of total billed charges,70% of total billed charges,89.11,48.48,,71.288,percent of total billed charges,48.48% of total billed charges,67.97,116.15,,,fee schedule,116.51% of cms physician fee schedule,89.11,48.48,,71.288,percent of total billed charges,48.48% of total billed charges,128.66,70,,102.928,percent of total billed charges,70% of total billed charges,128.66,70,,102.928,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,89.11,48.48,,71.288,percent of total billed charges,48.48% of total billed charges,165.42,90,,132.336,percent of total billed charges,90% of total billed charges,48.48,165.42,
SWING BED PRIVATE ROOM,,,110,RC,,,inpatient,,,800,480.00,,790,100,,,per diem,pays based on per day rate,3650,100,,,per diem,pays based on per day rate,744,93,,595.2,percent of total billed charges,93% of total billed charges ,744,93,,595.2,percent of total billed charges,93% of total billed charges,744,93,,595.2,percent of total billed charges,93% of total billed charges,1025,100,,,per diem ,pays based on per day rate,560,70,,448,percent of total billed charges,70% of total billed charges,3650,100,,,per diem ,pays based on per day rate,3650,100,,,per diem ,pay based on per day rate,3650,100,,,per diem,pays based on per day rate,560,70,,448,percent of total billed charges,70% of total billed charges,560,70,,448,percent of total billed charges,70% of total billed charges,1400,100,,,per diem,pays based on per day rate,1400,100,,,per diem,pays based on per day rate,720,90,,576,percent of total billed charges,90% of total billed charges,90,1400,
TELEMETRY ONE CHARGE PER DAY,36001005,CDM,730,RC,93041,HCPCS,outpatient,,,250,150.00,,150,60,,120,percent of total billed charges,60% of total billed charges,120,48,,96,percent of total billed charges,48% of total billed charges,49.35,100,,,fee schedule,100% of bcbs custom fee schedule,49.35,100,,,fee schedule,100% of bcbs custom fee schedule,54.78,111,,,fee schedule,111% of bcbs custom fee schedule,125,50,,100,percent of total billed charges,50% of total billed charges,175,70,,140,percent of total billed charges,70% of total billed charges,121.2,48.48,,96.96,percent of total billed charges,48.48% of total billed charges,6.53,116.15,,,fee schedule,116.51% of cms physician fee schedule,121.2,48.48,,96.96,percent of total billed charges,48.48% of total billed charges,175,70,,140,percent of total billed charges,70% of total billed charges,175,70,,140,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,121.2,48.48,,96.96,percent of total billed charges,48.48% of total billed charges,225,90,,180,percent of total billed charges,90% of total billed charges,48.48,225,
HOLTER REPORT,43102075,CDM,731,RC,93226,HCPCS,outpatient,,,213,127.80,,127.8,60,,102.24,percent of total billed charges,60% of total billed charges,102.24,48,,81.792,percent of total billed charges,48% of total billed charges,133.7,100,,,fee schedule,100% of bcbs custom fee schedule,133.7,100,,,fee schedule,100% of bcbs custom fee schedule,148.41,111,,,fee schedule,111% of bcbs custom fee schedule,106.5,50,,85.2,percent of total billed charges,50% of total billed charges,149.1,70,,119.28,percent of total billed charges,70% of total billed charges,103.26,48.48,,82.608,percent of total billed charges,48.48% of total billed charges,36.34,116.15,,,fee schedule,116.51% of cms physician fee schedule,103.26,48.48,,82.608,percent of total billed charges,48.48% of total billed charges,149.1,70,,119.28,percent of total billed charges,70% of total billed charges,149.1,70,,119.28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,103.26,48.48,,82.608,percent of total billed charges,48.48% of total billed charges,191.7,90,,153.36,percent of total billed charges,90% of total billed charges,48.48,191.7,
HOLTER MONITOR/24 HOURS,43509022,CDM,731,RC,93225,HCPCS,outpatient,,,200,120.00,,120,60,,96,percent of total billed charges,60% of total billed charges,96,48,,76.8,percent of total billed charges,48% of total billed charges,133.7,100,,,fee schedule,100% of bcbs custom fee schedule,133.7,100,,,fee schedule,100% of bcbs custom fee schedule,148.41,111,,,fee schedule,111% of bcbs custom fee schedule,100,50,,80,percent of total billed charges,50% of total billed charges,140,70,,112,percent of total billed charges,70% of total billed charges,96.96,48.48,,77.568,percent of total billed charges,48.48% of total billed charges,18.72,116.15,,,fee schedule,116.51% of cms physician fee schedule,96.96,48.48,,77.568,percent of total billed charges,48.48% of total billed charges,140,70,,112,percent of total billed charges,70% of total billed charges,140,70,,112,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,96.96,48.48,,77.568,percent of total billed charges,48.48% of total billed charges,180,90,,144,percent of total billed charges,90% of total billed charges,48.48,180,
AIRWAY,,,270,RC,,,outpatient,,,12.1,7.26,,7.26,60,,5.808,percent of total billed charges,60% of total billed charges,5.81,48,,4.648,percent of total billed charges,48% of total billed charges,6.05,50,,4.84,percent of total billed charges,50% of total billed charges,6.05,50,,4.84,percent of total billed charges,50% of total billed charges,6.05,50,,4.84,percent of total billed charges,50% of total billed charges,6.05,50,,4.84,percent of total billed charges,50% of total billed charges,8.47,70,,6.776,percent of total billed charges,70% of total billed charges,5.87,48.48,,4.696,percent of total billed charges,48.48% of total billed charges,5.87,48.48,,4.696,percent of total billed charges,48.48% of total billed charges,5.87,48.48,,4.696,percent of total billed charges,48.48% of total billed charges,8.47,70,,6.776,percent of total billed charges,70% of total billed charges,8.47,70,,6.776,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,5.87,48.48,,4.696,percent of total billed charges,48.48% of total billed charges,10.89,90,,8.712,percent of total billed charges,90% of total billed charges,5.87,90,
ETCO2,,,270,RC,,,outpatient,,,43.6,26.16,,26.16,60,,20.928,percent of total billed charges,60% of total billed charges,20.93,48,,16.744,percent of total billed charges,48% of total billed charges,21.8,50,,17.44,percent of total billed charges,50% of total billed charges,21.8,50,,17.44,percent of total billed charges,50% of total billed charges,21.8,50,,17.44,percent of total billed charges,50% of total billed charges,21.8,50,,17.44,percent of total billed charges,50% of total billed charges,30.52,70,,24.416,percent of total billed charges,70% of total billed charges,21.14,48.48,,16.912,percent of total billed charges,48.48% of total billed charges,21.14,48.48,,16.912,percent of total billed charges,48.48% of total billed charges,21.14,48.48,,16.912,percent of total billed charges,48.48% of total billed charges,30.52,70,,24.416,percent of total billed charges,70% of total billed charges,30.52,70,,24.416,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,21.14,48.48,,16.912,percent of total billed charges,48.48% of total billed charges,39.24,90,,31.392,percent of total billed charges,90% of total billed charges,21.14,90,
GROUP THERAPY PT,,,420,RC,97150,HCPCS,outpatient,,,51,30.60,,30.6,60,,24.48,percent of total billed charges,60% of total billed charges,24.48,48,,19.584,percent of total billed charges,48% of total billed charges,32.12,100,,,fee schedule,100% of bcbs custom fee schedule,32.12,100,,,fee schedule,100% of bcbs custom fee schedule,35.65,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,35.7,70,,28.56,percent of total billed charges,70% of total billed charges,24.72,48.48,,19.776,percent of total billed charges,48.48% of total billed charges,19.78,116.15,,,fee schedule,116.51% of cms physician fee schedule,24.72,48.48,,19.776,percent of total billed charges,48.48% of total billed charges,35.7,70,,28.56,percent of total billed charges,70% of total billed charges,35.7,70,,28.56,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,24.72,48.48,,19.776,percent of total billed charges,48.48% of total billed charges,45.9,90,,36.72,percent of total billed charges,90% of total billed charges,24.72,90,
PHYSICAL THERAPY RE-EVAL,48105319,CDM,424,RC,97164,HCPCS,outpatient,,,207,124.20,GP,124.2,60,,99.36,percent of total billed charges,60% of total billed charges,99.36,48,,79.488,percent of total billed charges,48% of total billed charges,103.11,100,,,fee schedule,100% of bcbs custom fee schedule,103.11,100,,,fee schedule,100% of bcbs custom fee schedule,114.45,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,144.9,70,,115.92,percent of total billed charges,70% of total billed charges,100.35,48.48,,80.28,percent of total billed charges,48.48% of total billed charges,75.69,116.15,,,fee schedule,116.51% of cms physician fee schedule,100.35,48.48,,80.28,percent of total billed charges,48.48% of total billed charges,144.9,70,,115.92,percent of total billed charges,70% of total billed charges,144.9,70,,115.92,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,100.35,48.48,,80.28,percent of total billed charges,48.48% of total billed charges,186.3,90,,149.04,percent of total billed charges,90% of total billed charges,48.48,186.3,
APPLICATION HOT/COLD PACK,73820111,CDM,420,RC,97010,HCPCS,outpatient,,,37.5,22.50,GP,22.5,60,,18,percent of total billed charges,60% of total billed charges,18,48,,14.4,percent of total billed charges,48% of total billed charges,7.11,100,,,fee schedule,100% of bcbs custom fee schedule,7.11,100,,,fee schedule,100% of bcbs custom fee schedule,7.89,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,26.25,70,,21,percent of total billed charges,70% of total billed charges,18.18,48.48,,14.544,percent of total billed charges,48.48% of total billed charges,6.82,116.15,,,fee schedule,116.51% of cms physician fee schedule,18.18,48.48,,14.544,percent of total billed charges,48.48% of total billed charges,26.25,70,,21,percent of total billed charges,70% of total billed charges,26.25,70,,21,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,18.18,48.48,,14.544,percent of total billed charges,48.48% of total billed charges,33.75,90,,27,percent of total billed charges,90% of total billed charges,18.18,90,
Respiratory Muscle Training Device,,,270,RC,,,outpatient,,,65,39.00,,39,60,,31.2,percent of total billed charges,60% of total billed charges,31.2,48,,24.96,percent of total billed charges,48% of total billed charges,32.5,50,,26,percent of total billed charges,50% of total billed charges,32.5,50,,26,percent of total billed charges,50% of total billed charges,32.5,50,,26,percent of total billed charges,50% of total billed charges,32.5,50,,26,percent of total billed charges,50% of total billed charges,45.5,70,,36.4,percent of total billed charges,70% of total billed charges,31.51,48.48,,25.208,percent of total billed charges,48.48% of total billed charges,31.51,48.48,,25.208,percent of total billed charges,48.48% of total billed charges,31.51,48.48,,25.208,percent of total billed charges,48.48% of total billed charges,45.5,70,,36.4,percent of total billed charges,70% of total billed charges,45.5,70,,36.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,31.51,48.48,,25.208,percent of total billed charges,48.48% of total billed charges,58.5,90,,46.8,percent of total billed charges,90% of total billed charges,31.51,90,
MECHANICAL TRACTION PT,48105130,CDM,420,RC,97012,HCPCS,outpatient,,,79,47.40,GP,47.4,60,,37.92,percent of total billed charges,60% of total billed charges,37.92,48,,30.336,percent of total billed charges,48% of total billed charges,27.48,100,,,fee schedule,100% of bcbs custom fee schedule,27.48,100,,,fee schedule,100% of bcbs custom fee schedule,30.5,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,55.3,70,,44.24,percent of total billed charges,70% of total billed charges,38.3,48.48,,30.64,percent of total billed charges,48.48% of total billed charges,15.52,116.15,,,fee schedule,116.51% of cms physician fee schedule,38.3,48.48,,30.64,percent of total billed charges,48.48% of total billed charges,55.3,70,,44.24,percent of total billed charges,70% of total billed charges,55.3,70,,44.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,38.3,48.48,,30.64,percent of total billed charges,48.48% of total billed charges,71.1,90,,56.88,percent of total billed charges,90% of total billed charges,38.3,90,
ELECTRICAL STIM- UNATTENDED PT,48105170,CDM,420,RC,97014,HCPCS,outpatient,,,79,47.40,,47.4,60,,37.92,percent of total billed charges,60% of total billed charges,37.92,48,,30.336,percent of total billed charges,48% of total billed charges,26.08,100,,,fee schedule,100% of bcbs custom fee schedule,26.08,100,,,fee schedule,100% of bcbs custom fee schedule,28.95,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,55.3,70,,44.24,percent of total billed charges,70% of total billed charges,38.3,48.48,,30.64,percent of total billed charges,48.48% of total billed charges,13.5,116.15,,,fee schedule,116.51% of cms physician fee schedule,38.3,48.48,,30.64,percent of total billed charges,48.48% of total billed charges,55.3,70,,44.24,percent of total billed charges,70% of total billed charges,55.3,70,,44.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,38.3,48.48,,30.64,percent of total billed charges,48.48% of total billed charges,71.1,90,,56.88,percent of total billed charges,90% of total billed charges,38.3,90,
VASOPNEUMATIC DEVICES,,,420,RC,97016,HCPCS,outpatient,,,95,57.00,GP,57,60,,45.6,percent of total billed charges,60% of total billed charges,45.6,48,,36.48,percent of total billed charges,48% of total billed charges,25.43,100,,,fee schedule,100% of bcbs custom fee schedule,25.43,100,,,fee schedule,100% of bcbs custom fee schedule,28.23,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,66.5,70,,53.2,percent of total billed charges,70% of total billed charges,46.06,48.48,,36.848,percent of total billed charges,48.48% of total billed charges,12.81,116.15,,,fee schedule,116.51% of cms physician fee schedule,46.06,48.48,,36.848,percent of total billed charges,48.48% of total billed charges,66.5,70,,53.2,percent of total billed charges,70% of total billed charges,66.5,70,,53.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,46.06,48.48,,36.848,percent of total billed charges,48.48% of total billed charges,85.5,90,,68.4,percent of total billed charges,90% of total billed charges,46.06,90,
PARAFFIN BATH PT,48105070,CDM,420,RC,97018,HCPCS,outpatient,,,54,32.40,GP,32.4,60,,25.92,percent of total billed charges,60% of total billed charges,25.92,48,,20.736,percent of total billed charges,48% of total billed charges,11.52,100,,,fee schedule,100% of bcbs custom fee schedule,11.52,100,,,fee schedule,100% of bcbs custom fee schedule,12.79,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,37.8,70,,30.24,percent of total billed charges,70% of total billed charges,26.18,48.48,,20.944,percent of total billed charges,48.48% of total billed charges,6.14,116.15,,,fee schedule,116.51% of cms physician fee schedule,26.18,48.48,,20.944,percent of total billed charges,48.48% of total billed charges,37.8,70,,30.24,percent of total billed charges,70% of total billed charges,37.8,70,,30.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,26.18,48.48,,20.944,percent of total billed charges,48.48% of total billed charges,48.6,90,,38.88,percent of total billed charges,90% of total billed charges,26.18,90,
ELECTRICAL STIM- ATTENDED PT,48105171,CDM,420,RC,97032,HCPCS,outpatient,,,95,57.00,GP,57,60,,45.6,percent of total billed charges,60% of total billed charges,45.6,48,,36.48,percent of total billed charges,48% of total billed charges,29.38,100,,,fee schedule,100% of bcbs custom fee schedule,29.38,100,,,fee schedule,100% of bcbs custom fee schedule,32.61,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,66.5,70,,53.2,percent of total billed charges,70% of total billed charges,46.06,48.48,,36.848,percent of total billed charges,48.48% of total billed charges,15.85,116.15,,,fee schedule,116.51% of cms physician fee schedule,46.06,48.48,,36.848,percent of total billed charges,48.48% of total billed charges,66.5,70,,53.2,percent of total billed charges,70% of total billed charges,66.5,70,,53.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,46.06,48.48,,36.848,percent of total billed charges,48.48% of total billed charges,85.5,90,,68.4,percent of total billed charges,90% of total billed charges,46.06,90,
IONTOPHORESIS PT,48105272,CDM,420,RC,97033,HCPCS,outpatient,,,130,78.00,GP,78,60,,62.4,percent of total billed charges,60% of total billed charges,62.4,48,,49.92,percent of total billed charges,48% of total billed charges,37.02,100,,,fee schedule,100% of bcbs custom fee schedule,37.02,100,,,fee schedule,100% of bcbs custom fee schedule,41.09,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,91,70,,72.8,percent of total billed charges,70% of total billed charges,63.02,48.48,,50.416,percent of total billed charges,48.48% of total billed charges,20.99,116.15,,,fee schedule,116.51% of cms physician fee schedule,63.02,48.48,,50.416,percent of total billed charges,48.48% of total billed charges,91,70,,72.8,percent of total billed charges,70% of total billed charges,91,70,,72.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,63.02,48.48,,50.416,percent of total billed charges,48.48% of total billed charges,117,90,,93.6,percent of total billed charges,90% of total billed charges,48.48,117,
IONTOPHORESIS OT,48105272,CDM,430,RC,97033,HCPCS,outpatient,,,130,78.00,GP,78,60,,62.4,percent of total billed charges,60% of total billed charges,62.4,48,,49.92,percent of total billed charges,48% of total billed charges,37.02,100,,,fee schedule,100% of bcbs custom fee schedule,37.02,100,,,fee schedule,100% of bcbs custom fee schedule,41.09,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,91,70,,72.8,percent of total billed charges,70% of total billed charges,63.02,48.48,,50.416,percent of total billed charges,48.48% of total billed charges,20.99,116.15,,,fee schedule,116.51% of cms physician fee schedule,63.02,48.48,,50.416,percent of total billed charges,48.48% of total billed charges,91,70,,72.8,percent of total billed charges,70% of total billed charges,91,70,,72.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,63.02,48.48,,50.416,percent of total billed charges,48.48% of total billed charges,117,90,,93.6,percent of total billed charges,90% of total billed charges,48.48,117,
ULTRASOUND THERAPY PT,48105100,CDM,420,RC,97035,HCPCS,outpatient,,,87.5,52.50,GP,52.5,60,,42,percent of total billed charges,60% of total billed charges,42,48,,33.6,percent of total billed charges,48% of total billed charges,22.64,100,,,fee schedule,100% of bcbs custom fee schedule,22.64,100,,,fee schedule,100% of bcbs custom fee schedule,25.13,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,61.25,70,,49,percent of total billed charges,70% of total billed charges,42.42,48.48,,33.936,percent of total billed charges,48.48% of total billed charges,15.33,116.15,,,fee schedule,116.51% of cms physician fee schedule,42.42,48.48,,33.936,percent of total billed charges,48.48% of total billed charges,61.25,70,,49,percent of total billed charges,70% of total billed charges,61.25,70,,49,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,42.42,48.48,,33.936,percent of total billed charges,48.48% of total billed charges,78.75,90,,63,percent of total billed charges,90% of total billed charges,42.42,90,
THERAPEUTIC EXERCISE PT,48105140,CDM,420,RC,97110,HCPCS,outpatient,,,172,103.20,GP,103.2,60,,82.56,percent of total billed charges,60% of total billed charges,82.56,48,,66.048,percent of total billed charges,48% of total billed charges,51.9,100,,,fee schedule,100% of bcbs custom fee schedule,51.9,100,,,fee schedule,100% of bcbs custom fee schedule,57.61,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,120.4,70,,96.32,percent of total billed charges,70% of total billed charges,83.39,48.48,,66.712,percent of total billed charges,48.48% of total billed charges,32.06,116.15,,,fee schedule,116.51% of cms physician fee schedule,83.39,48.48,,66.712,percent of total billed charges,48.48% of total billed charges,120.4,70,,96.32,percent of total billed charges,70% of total billed charges,120.4,70,,96.32,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,83.39,48.48,,66.712,percent of total billed charges,48.48% of total billed charges,154.8,90,,123.84,percent of total billed charges,90% of total billed charges,48.48,154.8,
NEUROMUSCULAR RE-ED PT,48105275,CDM,420,RC,97112,HCPCS,outpatient,,,166,99.60,,99.6,60,,79.68,percent of total billed charges,60% of total billed charges,79.68,48,,63.744,percent of total billed charges,48% of total billed charges,53.63,100,,,fee schedule,100% of bcbs custom fee schedule,53.63,100,,,fee schedule,100% of bcbs custom fee schedule,59.53,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,116.2,70,,92.96,percent of total billed charges,70% of total billed charges,80.48,48.48,,64.384,percent of total billed charges,48.48% of total billed charges,36.7,116.15,,,fee schedule,116.51% of cms physician fee schedule,80.48,48.48,,64.384,percent of total billed charges,48.48% of total billed charges,116.2,70,,92.96,percent of total billed charges,70% of total billed charges,116.2,70,,92.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,80.48,48.48,,64.384,percent of total billed charges,48.48% of total billed charges,149.4,90,,119.52,percent of total billed charges,90% of total billed charges,48.48,149.4,
PHYSICAL THERAPY GAIT TR,48105090,CDM,420,RC,97116,HCPCS,outpatient,,,160,96.00,GP,96,60,,76.8,percent of total billed charges,60% of total billed charges,76.8,48,,61.44,percent of total billed charges,48% of total billed charges,45.53,100,,,fee schedule,100% of bcbs custom fee schedule,45.53,100,,,fee schedule,100% of bcbs custom fee schedule,50.54,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,112,70,,89.6,percent of total billed charges,70% of total billed charges,77.57,48.48,,62.056,percent of total billed charges,48.48% of total billed charges,32.06,116.15,,,fee schedule,116.51% of cms physician fee schedule,77.57,48.48,,62.056,percent of total billed charges,48.48% of total billed charges,112,70,,89.6,percent of total billed charges,70% of total billed charges,112,70,,89.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,77.57,48.48,,62.056,percent of total billed charges,48.48% of total billed charges,144,90,,115.2,percent of total billed charges,90% of total billed charges,48.48,144,
PHYSICAL THERAPY MASSAGE,48105120,CDM,420,RC,97124,HCPCS,outpatient,,,131,78.60,GP,78.6,60,,62.88,percent of total billed charges,60% of total billed charges,62.88,48,,50.304,percent of total billed charges,48% of total billed charges,41.19,100,,,fee schedule,100% of bcbs custom fee schedule,41.19,100,,,fee schedule,100% of bcbs custom fee schedule,45.72,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,91.7,70,,73.36,percent of total billed charges,70% of total billed charges,63.51,48.48,,50.808,percent of total billed charges,48.48% of total billed charges,32.59,116.15,,,fee schedule,116.51% of cms physician fee schedule,63.51,48.48,,50.808,percent of total billed charges,48.48% of total billed charges,91.7,70,,73.36,percent of total billed charges,70% of total billed charges,91.7,70,,73.36,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,63.51,48.48,,50.808,percent of total billed charges,48.48% of total billed charges,117.9,90,,94.32,percent of total billed charges,90% of total billed charges,48.48,117.9,
MANUAL THERAPY PT,48105297,CDM,420,RC,97140,HCPCS,outpatient,,,147,88.20,GP,88.2,60,,70.56,percent of total billed charges,60% of total billed charges,70.56,48,,56.448,percent of total billed charges,48% of total billed charges,48.38,100,,,fee schedule,100% of bcbs custom fee schedule,48.38,100,,,fee schedule,100% of bcbs custom fee schedule,53.7,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,102.9,70,,82.32,percent of total billed charges,70% of total billed charges,71.27,48.48,,57.016,percent of total billed charges,48.48% of total billed charges,29.6,116.15,,,fee schedule,116.51% of cms physician fee schedule,71.27,48.48,,57.016,percent of total billed charges,48.48% of total billed charges,102.9,70,,82.32,percent of total billed charges,70% of total billed charges,102.9,70,,82.32,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,71.27,48.48,,57.016,percent of total billed charges,48.48% of total billed charges,132.3,90,,105.84,percent of total billed charges,90% of total billed charges,48.48,132.3,
THERAPEUTIC ACTIVITIES PT,48105287,CDM,420,RC,97530,HCPCS,outpatient,,,172,103.20,GP,103.2,60,,82.56,percent of total billed charges,60% of total billed charges,82.56,48,,66.048,percent of total billed charges,48% of total billed charges,53.52,100,,,fee schedule,100% of bcbs custom fee schedule,53.52,100,,,fee schedule,100% of bcbs custom fee schedule,59.41,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,120.4,70,,96.32,percent of total billed charges,70% of total billed charges,83.39,48.48,,66.712,percent of total billed charges,48.48% of total billed charges,39.47,116.15,,,fee schedule,116.51% of cms physician fee schedule,83.39,48.48,,66.712,percent of total billed charges,48.48% of total billed charges,120.4,70,,96.32,percent of total billed charges,70% of total billed charges,120.4,70,,96.32,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,83.39,48.48,,66.712,percent of total billed charges,48.48% of total billed charges,154.8,90,,123.84,percent of total billed charges,90% of total billed charges,48.48,154.8,
WHEELCHAIR MGMT PT,,,420,RC,97542,HCPCS,outpatient,,,75,45.00,GP,45,60,,36,percent of total billed charges,60% of total billed charges,36,48,,28.8,percent of total billed charges,48% of total billed charges,51.73,100,,,fee schedule,100% of bcbs custom fee schedule,51.73,100,,,fee schedule,100% of bcbs custom fee schedule,57.42,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,52.5,70,,42,percent of total billed charges,70% of total billed charges,36.36,48.48,,29.088,percent of total billed charges,48.48% of total billed charges,34.58,116.15,,,fee schedule,116.51% of cms physician fee schedule,36.36,48.48,,29.088,percent of total billed charges,48.48% of total billed charges,52.5,70,,42,percent of total billed charges,70% of total billed charges,52.5,70,,42,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,36.36,48.48,,29.088,percent of total billed charges,48.48% of total billed charges,67.5,90,,54,percent of total billed charges,90% of total billed charges,36.36,90,
Non Selective Debridement,44500003,CDM,420,RC,97602,HCPCS,outpatient,,,353.49,212.09,GP,212.09,60,,169.672,percent of total billed charges,60% of total billed charges,169.68,48,,135.744,percent of total billed charges,48% of total billed charges,259.25,100,,,fee schedule,100% of bcbs custom fee schedule,259.25,100,,,fee schedule,100% of bcbs custom fee schedule,287.77,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,247.44,70,,197.952,percent of total billed charges,70% of total billed charges,171.37,48.48,,137.096,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,171.37,48.48,,137.096,percent of total billed charges,48.48% of total billed charges,247.44,70,,197.952,percent of total billed charges,70% of total billed charges,247.44,70,,197.952,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,171.37,48.48,,137.096,percent of total billed charges,48.48% of total billed charges,318.14,90,,254.512,percent of total billed charges,90% of total billed charges,48.48,318.14,
DEBRIDEMNT SELECT< 20 CM,36000015,CDM,420,RC,97597,HCPCS,outpatient,,,280.95,168.57,GP,399,100,,,fee schedule,100% of asc tier groupings rate,134.86,48,,107.888,percent of total billed charges,48% of total billed charges,111.01,100,,,fee schedule,100% of bcbs custom fee schedule,111.01,100,,,fee schedule,100% of bcbs custom fee schedule,123.22,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,196.67,70,,157.336,percent of total billed charges,70% of total billed charges,136.2,48.48,,108.96,percent of total billed charges,48.48% of total billed charges,39.87,116.15,,,fee schedule,116.51% of cms physician fee schedule,136.2,48.48,,108.96,percent of total billed charges,48.48% of total billed charges,196.67,70,,157.336,percent of total billed charges,70% of total billed charges,196.67,70,,157.336,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,136.2,48.48,,108.96,percent of total billed charges,48.48% of total billed charges,252.86,90,,202.288,percent of total billed charges,90% of total billed charges,48.48,252.86,
PT EVAL- LOW COMPX,48105316,CDM,424,RC,97161,HCPCS,outpatient,,,399,239.40,GP,239.4,60,,191.52,percent of total billed charges,60% of total billed charges,191.52,48,,153.216,percent of total billed charges,48% of total billed charges,140.03,100,,,fee schedule,100% of bcbs custom fee schedule,140.03,100,,,fee schedule,100% of bcbs custom fee schedule,155.43,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,279.3,70,,223.44,percent of total billed charges,70% of total billed charges,193.44,48.48,,154.752,percent of total billed charges,48.48% of total billed charges,109.74,116.15,,,fee schedule,116.51% of cms physician fee schedule,193.44,48.48,,154.752,percent of total billed charges,48.48% of total billed charges,279.3,70,,223.44,percent of total billed charges,70% of total billed charges,279.3,70,,223.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,193.44,48.48,,154.752,percent of total billed charges,48.48% of total billed charges,359.1,90,,287.28,percent of total billed charges,90% of total billed charges,48.48,359.1,
PT EVAL- MODERATE COMPLX,48105317,CDM,424,RC,97162,HCPCS,outpatient,,,399,239.40,GP,239.4,60,,191.52,percent of total billed charges,60% of total billed charges,191.52,48,,153.216,percent of total billed charges,48% of total billed charges,140.03,100,,,fee schedule,100% of bcbs custom fee schedule,140.03,100,,,fee schedule,100% of bcbs custom fee schedule,155.43,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,279.3,70,,223.44,percent of total billed charges,70% of total billed charges,193.44,48.48,,154.752,percent of total billed charges,48.48% of total billed charges,109.74,116.15,,,fee schedule,116.51% of cms physician fee schedule,193.44,48.48,,154.752,percent of total billed charges,48.48% of total billed charges,279.3,70,,223.44,percent of total billed charges,70% of total billed charges,279.3,70,,223.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,193.44,48.48,,154.752,percent of total billed charges,48.48% of total billed charges,359.1,90,,287.28,percent of total billed charges,90% of total billed charges,48.48,359.1,
PT EVAL- HIGH COMPLX,48105318,CDM,424,RC,97163,HCPCS,outpatient,,,399,239.40,GP,239.4,60,,191.52,percent of total billed charges,60% of total billed charges,191.52,48,,153.216,percent of total billed charges,48% of total billed charges,140.03,100,,,fee schedule,100% of bcbs custom fee schedule,140.03,100,,,fee schedule,100% of bcbs custom fee schedule,155.43,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,279.3,70,,223.44,percent of total billed charges,70% of total billed charges,193.44,48.48,,154.752,percent of total billed charges,48.48% of total billed charges,109.74,116.15,,,fee schedule,116.51% of cms physician fee schedule,193.44,48.48,,154.752,percent of total billed charges,48.48% of total billed charges,279.3,70,,223.44,percent of total billed charges,70% of total billed charges,279.3,70,,223.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,193.44,48.48,,154.752,percent of total billed charges,48.48% of total billed charges,359.1,90,,287.28,percent of total billed charges,90% of total billed charges,48.48,359.1,
OT EVAL- LOW COMPLX,48207070,CDM,434,RC,97165,HCPCS,outpatient,,,386.75,232.05,GO,232.05,60,,185.64,percent of total billed charges,60% of total billed charges,185.64,48,,148.512,percent of total billed charges,48% of total billed charges,148.95,100,,,fee schedule,100% of bcbs custom fee schedule,148.95,100,,,fee schedule,100% of bcbs custom fee schedule,165.33,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,270.73,70,,216.584,percent of total billed charges,70% of total billed charges,187.5,48.48,,150,percent of total billed charges,48.48% of total billed charges,110.75,116.15,,,fee schedule,116.51% of cms physician fee schedule,187.5,48.48,,150,percent of total billed charges,48.48% of total billed charges,270.73,70,,216.584,percent of total billed charges,70% of total billed charges,270.73,70,,216.584,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,187.5,48.48,,150,percent of total billed charges,48.48% of total billed charges,348.08,90,,278.464,percent of total billed charges,90% of total billed charges,48.48,348.08,
OT EVAL -MODERATE COMPLX,48207071,CDM,434,RC,97166,HCPCS,outpatient,,,386.75,232.05,GO,232.05,60,,185.64,percent of total billed charges,60% of total billed charges,185.64,48,,148.512,percent of total billed charges,48% of total billed charges,148.95,100,,,fee schedule,100% of bcbs custom fee schedule,148.95,100,,,fee schedule,100% of bcbs custom fee schedule,165.33,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,270.73,70,,216.584,percent of total billed charges,70% of total billed charges,187.5,48.48,,150,percent of total billed charges,48.48% of total billed charges,110.75,116.15,,,fee schedule,116.51% of cms physician fee schedule,187.5,48.48,,150,percent of total billed charges,48.48% of total billed charges,270.73,70,,216.584,percent of total billed charges,70% of total billed charges,270.73,70,,216.584,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,187.5,48.48,,150,percent of total billed charges,48.48% of total billed charges,348.08,90,,278.464,percent of total billed charges,90% of total billed charges,48.48,348.08,
OT EVAL- HIGH COMPLX,48207072,CDM,434,RC,97167,HCPCS,outpatient,,,386.75,232.05,GO,232.05,60,,185.64,percent of total billed charges,60% of total billed charges,185.64,48,,148.512,percent of total billed charges,48% of total billed charges,148.95,100,,,fee schedule,100% of bcbs custom fee schedule,148.95,100,,,fee schedule,100% of bcbs custom fee schedule,165.33,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,270.73,70,,216.584,percent of total billed charges,70% of total billed charges,187.5,48.48,,150,percent of total billed charges,48.48% of total billed charges,110.75,116.15,,,fee schedule,116.51% of cms physician fee schedule,187.5,48.48,,150,percent of total billed charges,48.48% of total billed charges,270.73,70,,216.584,percent of total billed charges,70% of total billed charges,270.73,70,,216.584,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,187.5,48.48,,150,percent of total billed charges,48.48% of total billed charges,348.08,90,,278.464,percent of total billed charges,90% of total billed charges,48.48,348.08,
DEBRD WD SURFACE <20 SQCM,43601432,CDM,420,RC,97598,HCPCS,outpatient,,,131.28,78.77,GP,399,100,,,fee schedule,100% of asc tier groupings rate,63.01,48,,50.408,percent of total billed charges,48% of total billed charges,138.83,100,,,fee schedule,100% of bcbs custom fee schedule,138.83,100,,,fee schedule,100% of bcbs custom fee schedule,154.1,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,91.9,70,,73.52,percent of total billed charges,70% of total billed charges,63.64,48.48,,50.912,percent of total billed charges,48.48% of total billed charges,27.74,116.15,,,fee schedule,116.51% of cms physician fee schedule,63.64,48.48,,50.912,percent of total billed charges,48.48% of total billed charges,91.9,70,,73.52,percent of total billed charges,70% of total billed charges,91.9,70,,73.52,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,63.64,48.48,,50.912,percent of total billed charges,48.48% of total billed charges,118.15,90,,94.52,percent of total billed charges,90% of total billed charges,48.48,118.15,
UNNA BOOT,43601396,CDM,420,RC,29580,HCPCS,outpatient,,,180.81,108.49,GP,108.49,60,,86.792,percent of total billed charges,60% of total billed charges,86.79,48,,69.432,percent of total billed charges,48% of total billed charges,325.87,100,,,fee schedule,100% of bcbs custom fee schedule,325.87,100,,,fee schedule,100% of bcbs custom fee schedule,361.72,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,126.57,70,,101.256,percent of total billed charges,70% of total billed charges,87.66,48.48,,70.128,percent of total billed charges,48.48% of total billed charges,29.77,116.15,,,fee schedule,116.51% of cms physician fee schedule,87.66,48.48,,70.128,percent of total billed charges,48.48% of total billed charges,126.57,70,,101.256,percent of total billed charges,70% of total billed charges,126.57,70,,101.256,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,87.66,48.48,,70.128,percent of total billed charges,48.48% of total billed charges,162.73,90,,130.184,percent of total billed charges,90% of total billed charges,48.48,162.73,
PT SELF-CARE/HOME MGMT TRANG EA 15 MINS,48105267,CDM,420,RC,97535,HCPCS,outpatient,,,173,103.80,,103.8,60,,83.04,percent of total billed charges,60% of total billed charges,83.04,48,,66.432,percent of total billed charges,48% of total billed charges,54.88,100,,,fee schedule,100% of bcbs custom fee schedule,54.88,100,,,fee schedule,100% of bcbs custom fee schedule,60.92,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,121.1,70,,96.88,percent of total billed charges,70% of total billed charges,83.87,48.48,,67.096,percent of total billed charges,48.48% of total billed charges,35.45,116.15,,,fee schedule,116.51% of cms physician fee schedule,83.87,48.48,,67.096,percent of total billed charges,48.48% of total billed charges,121.1,70,,96.88,percent of total billed charges,70% of total billed charges,121.1,70,,96.88,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,83.87,48.48,,67.096,percent of total billed charges,48.48% of total billed charges,155.7,90,,124.56,percent of total billed charges,90% of total billed charges,48.48,155.7,
OT RE-EVALUATION,48207073,CDM,434,RC,97168,HCPCS,outpatient,,,259,155.40,GO,155.4,60,,124.32,percent of total billed charges,60% of total billed charges,124.32,48,,99.456,percent of total billed charges,48% of total billed charges,128.71,100,,,fee schedule,100% of bcbs custom fee schedule,128.71,100,,,fee schedule,100% of bcbs custom fee schedule,142.87,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,181.3,70,,145.04,percent of total billed charges,70% of total billed charges,125.56,48.48,,100.448,percent of total billed charges,48.48% of total billed charges,76.03,116.15,,,fee schedule,116.51% of cms physician fee schedule,125.56,48.48,,100.448,percent of total billed charges,48.48% of total billed charges,181.3,70,,145.04,percent of total billed charges,70% of total billed charges,181.3,70,,145.04,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,125.56,48.48,,100.448,percent of total billed charges,48.48% of total billed charges,233.1,90,,186.48,percent of total billed charges,90% of total billed charges,48.48,233.1,
ADL OT,48105267,CDM,430,RC,97535,HCPCS,outpatient,,,173,103.80,GO,103.8,60,,83.04,percent of total billed charges,60% of total billed charges,83.04,48,,66.432,percent of total billed charges,48% of total billed charges,54.88,100,,,fee schedule,100% of bcbs custom fee schedule,54.88,100,,,fee schedule,100% of bcbs custom fee schedule,60.92,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,121.1,70,,96.88,percent of total billed charges,70% of total billed charges,83.87,48.48,,67.096,percent of total billed charges,48.48% of total billed charges,35.45,116.15,,,fee schedule,116.51% of cms physician fee schedule,83.87,48.48,,67.096,percent of total billed charges,48.48% of total billed charges,121.1,70,,96.88,percent of total billed charges,70% of total billed charges,121.1,70,,96.88,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,83.87,48.48,,67.096,percent of total billed charges,48.48% of total billed charges,155.7,90,,124.56,percent of total billed charges,90% of total billed charges,48.48,155.7,
ELECTRICAL STIM- ATTENDED OT,48105171,CDM,430,RC,97032,HCPCS,outpatient,,,79,47.40,,47.4,60,,37.92,percent of total billed charges,60% of total billed charges,37.92,48,,30.336,percent of total billed charges,48% of total billed charges,29.38,100,,,fee schedule,100% of bcbs custom fee schedule,29.38,100,,,fee schedule,100% of bcbs custom fee schedule,32.61,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,55.3,70,,44.24,percent of total billed charges,70% of total billed charges,38.3,48.48,,30.64,percent of total billed charges,48.48% of total billed charges,15.85,116.15,,,fee schedule,116.51% of cms physician fee schedule,38.3,48.48,,30.64,percent of total billed charges,48.48% of total billed charges,55.3,70,,44.24,percent of total billed charges,70% of total billed charges,55.3,70,,44.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,38.3,48.48,,30.64,percent of total billed charges,48.48% of total billed charges,71.1,90,,56.88,percent of total billed charges,90% of total billed charges,38.3,90,
ELECTRICAL STIM- UNATTENDED OT,48105170,CDM,430,RC,97014,HCPCS,outpatient,,,79,47.40,,47.4,60,,37.92,percent of total billed charges,60% of total billed charges,37.92,48,,30.336,percent of total billed charges,48% of total billed charges,26.08,100,,,fee schedule,100% of bcbs custom fee schedule,26.08,100,,,fee schedule,100% of bcbs custom fee schedule,28.95,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,55.3,70,,44.24,percent of total billed charges,70% of total billed charges,38.3,48.48,,30.64,percent of total billed charges,48.48% of total billed charges,13.5,116.15,,,fee schedule,116.51% of cms physician fee schedule,38.3,48.48,,30.64,percent of total billed charges,48.48% of total billed charges,55.3,70,,44.24,percent of total billed charges,70% of total billed charges,55.3,70,,44.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,38.3,48.48,,30.64,percent of total billed charges,48.48% of total billed charges,71.1,90,,56.88,percent of total billed charges,90% of total billed charges,38.3,90,
PARAFFIN BATH OT,48105070,CDM,430,RC,97018,HCPCS,outpatient,,,54,32.40,GO,32.4,60,,25.92,percent of total billed charges,60% of total billed charges,25.92,48,,20.736,percent of total billed charges,48% of total billed charges,11.52,100,,,fee schedule,100% of bcbs custom fee schedule,11.52,100,,,fee schedule,100% of bcbs custom fee schedule,12.79,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,37.8,70,,30.24,percent of total billed charges,70% of total billed charges,26.18,48.48,,20.944,percent of total billed charges,48.48% of total billed charges,6.14,116.15,,,fee schedule,116.51% of cms physician fee schedule,26.18,48.48,,20.944,percent of total billed charges,48.48% of total billed charges,37.8,70,,30.24,percent of total billed charges,70% of total billed charges,37.8,70,,30.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,26.18,48.48,,20.944,percent of total billed charges,48.48% of total billed charges,48.6,90,,38.88,percent of total billed charges,90% of total billed charges,26.18,90,
ULTRASOUND THERAPY OT,48105100,CDM,430,RC,97035,HCPCS,outpatient,,,87.5,52.50,GO,52.5,60,,42,percent of total billed charges,60% of total billed charges,42,48,,33.6,percent of total billed charges,48% of total billed charges,22.64,100,,,fee schedule,100% of bcbs custom fee schedule,22.64,100,,,fee schedule,100% of bcbs custom fee schedule,25.13,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,61.25,70,,49,percent of total billed charges,70% of total billed charges,42.42,48.48,,33.936,percent of total billed charges,48.48% of total billed charges,15.33,116.15,,,fee schedule,116.51% of cms physician fee schedule,42.42,48.48,,33.936,percent of total billed charges,48.48% of total billed charges,61.25,70,,49,percent of total billed charges,70% of total billed charges,61.25,70,,49,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,42.42,48.48,,33.936,percent of total billed charges,48.48% of total billed charges,78.75,90,,63,percent of total billed charges,90% of total billed charges,42.42,90,
OT PROCEDURE,48105287,CDM,430,RC,97530,HCPCS,outpatient,,,172,103.20,GO,103.2,60,,82.56,percent of total billed charges,60% of total billed charges,82.56,48,,66.048,percent of total billed charges,48% of total billed charges,53.52,100,,,fee schedule,100% of bcbs custom fee schedule,53.52,100,,,fee schedule,100% of bcbs custom fee schedule,59.41,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,120.4,70,,96.32,percent of total billed charges,70% of total billed charges,83.39,48.48,,66.712,percent of total billed charges,48.48% of total billed charges,39.47,116.15,,,fee schedule,116.51% of cms physician fee schedule,83.39,48.48,,66.712,percent of total billed charges,48.48% of total billed charges,120.4,70,,96.32,percent of total billed charges,70% of total billed charges,120.4,70,,96.32,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,83.39,48.48,,66.712,percent of total billed charges,48.48% of total billed charges,154.8,90,,123.84,percent of total billed charges,90% of total billed charges,48.48,154.8,
NEUROMUSCULAR RE-ED OT,48105275,CDM,430,RC,97112,HCPCS,outpatient,,,166,99.60,,99.6,60,,79.68,percent of total billed charges,60% of total billed charges,79.68,48,,63.744,percent of total billed charges,48% of total billed charges,53.63,100,,,fee schedule,100% of bcbs custom fee schedule,53.63,100,,,fee schedule,100% of bcbs custom fee schedule,59.53,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,116.2,70,,92.96,percent of total billed charges,70% of total billed charges,80.48,48.48,,64.384,percent of total billed charges,48.48% of total billed charges,36.7,116.15,,,fee schedule,116.51% of cms physician fee schedule,80.48,48.48,,64.384,percent of total billed charges,48.48% of total billed charges,116.2,70,,92.96,percent of total billed charges,70% of total billed charges,116.2,70,,92.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,80.48,48.48,,64.384,percent of total billed charges,48.48% of total billed charges,149.4,90,,119.52,percent of total billed charges,90% of total billed charges,48.48,149.4,
OCCUPAT THERAPY MASSAGE,48105120,CDM,430,RC,97124,HCPCS,outpatient,,,131,78.60,,78.6,60,,62.88,percent of total billed charges,60% of total billed charges,62.88,48,,50.304,percent of total billed charges,48% of total billed charges,41.19,100,,,fee schedule,100% of bcbs custom fee schedule,41.19,100,,,fee schedule,100% of bcbs custom fee schedule,45.72,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,91.7,70,,73.36,percent of total billed charges,70% of total billed charges,63.51,48.48,,50.808,percent of total billed charges,48.48% of total billed charges,32.59,116.15,,,fee schedule,116.51% of cms physician fee schedule,63.51,48.48,,50.808,percent of total billed charges,48.48% of total billed charges,91.7,70,,73.36,percent of total billed charges,70% of total billed charges,91.7,70,,73.36,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,63.51,48.48,,50.808,percent of total billed charges,48.48% of total billed charges,117.9,90,,94.32,percent of total billed charges,90% of total billed charges,48.48,117.9,
MANUAL THERAPY OT,48105297,CDM,430,RC,97140,HCPCS,outpatient,,,147,88.20,GO,88.2,60,,70.56,percent of total billed charges,60% of total billed charges,70.56,48,,56.448,percent of total billed charges,48% of total billed charges,48.38,100,,,fee schedule,100% of bcbs custom fee schedule,48.38,100,,,fee schedule,100% of bcbs custom fee schedule,53.7,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,102.9,70,,82.32,percent of total billed charges,70% of total billed charges,71.27,48.48,,57.016,percent of total billed charges,48.48% of total billed charges,29.6,116.15,,,fee schedule,116.51% of cms physician fee schedule,71.27,48.48,,57.016,percent of total billed charges,48.48% of total billed charges,102.9,70,,82.32,percent of total billed charges,70% of total billed charges,102.9,70,,82.32,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,71.27,48.48,,57.016,percent of total billed charges,48.48% of total billed charges,132.3,90,,105.84,percent of total billed charges,90% of total billed charges,48.48,132.3,
Cognskills Development OT,48200128,CDM,430,RC,97129,HCPCS,outpatient,,,55.59,33.35,,33.35,60,,26.68,percent of total billed charges,60% of total billed charges,26.68,48,,21.344,percent of total billed charges,48% of total billed charges,0.01,100,,,fee schedule,100% of bcbs custom fee schedule,0.01,100,,,fee schedule,100% of bcbs custom fee schedule,0.01,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,38.91,70,,31.128,percent of total billed charges,70% of total billed charges,26.95,48.48,,21.56,percent of total billed charges,48.48% of total billed charges,24.84,116.15,,,fee schedule,116.51% of cms physician fee schedule,26.95,48.48,,21.56,percent of total billed charges,48.48% of total billed charges,38.91,70,,31.128,percent of total billed charges,70% of total billed charges,38.91,70,,31.128,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,26.95,48.48,,21.56,percent of total billed charges,48.48% of total billed charges,50.03,90,,40.024,percent of total billed charges,90% of total billed charges,26.95,90,
THERAPEUTIC ACTIVITIES OT,48105287,CDM,430,RC,97530,HCPCS,outpatient,,,172,103.20,GO,103.2,60,,82.56,percent of total billed charges,60% of total billed charges,82.56,48,,66.048,percent of total billed charges,48% of total billed charges,53.52,100,,,fee schedule,100% of bcbs custom fee schedule,53.52,100,,,fee schedule,100% of bcbs custom fee schedule,59.41,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,120.4,70,,96.32,percent of total billed charges,70% of total billed charges,83.39,48.48,,66.712,percent of total billed charges,48.48% of total billed charges,39.47,116.15,,,fee schedule,116.51% of cms physician fee schedule,83.39,48.48,,66.712,percent of total billed charges,48.48% of total billed charges,120.4,70,,96.32,percent of total billed charges,70% of total billed charges,120.4,70,,96.32,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,83.39,48.48,,66.712,percent of total billed charges,48.48% of total billed charges,154.8,90,,123.84,percent of total billed charges,90% of total billed charges,48.48,154.8,
COGNITIVE FUNC EA. ADD 15 MINS,48200129,CDM,430,RC,97130,HCPCS,outpatient,,,114.95,68.97,,68.97,60,,55.176,percent of total billed charges,60% of total billed charges,55.18,48,,44.144,percent of total billed charges,48% of total billed charges,0.01,100,,,fee schedule,100% of bcbs custom fee schedule,0.01,100,,,fee schedule,100% of bcbs custom fee schedule,0.01,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,80.47,70,,64.376,percent of total billed charges,70% of total billed charges,55.73,48.48,,44.584,percent of total billed charges,48.48% of total billed charges,23.74,116.15,,,fee schedule,116.51% of cms physician fee schedule,55.73,48.48,,44.584,percent of total billed charges,48.48% of total billed charges,80.47,70,,64.376,percent of total billed charges,70% of total billed charges,80.47,70,,64.376,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,55.73,48.48,,44.584,percent of total billed charges,48.48% of total billed charges,103.46,90,,82.768,percent of total billed charges,90% of total billed charges,48.48,103.46,
Sensory Integration-OT,,,430,RC,97533,HCPCS,outpatient,,,46.41,27.85,,27.85,60,,22.28,percent of total billed charges,60% of total billed charges,22.28,48,,17.824,percent of total billed charges,48% of total billed charges,48.49,100,,,fee schedule,100% of bcbs custom fee schedule,48.49,100,,,fee schedule,100% of bcbs custom fee schedule,53.82,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,32.49,70,,25.992,percent of total billed charges,70% of total billed charges,22.5,48.48,,18,percent of total billed charges,48.48% of total billed charges,65.73,116.15,,,fee schedule,116.51% of cms physician fee schedule,22.5,48.48,,18,percent of total billed charges,48.48% of total billed charges,32.49,70,,25.992,percent of total billed charges,70% of total billed charges,32.49,70,,25.992,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,22.5,48.48,,18,percent of total billed charges,48.48% of total billed charges,41.77,90,,33.416,percent of total billed charges,90% of total billed charges,22.5,90,
WHEELCHAIR MGMT OT,,,430,RC,97542,HCPCS,outpatient,,,75,45.00,GO,45,60,,36,percent of total billed charges,60% of total billed charges,36,48,,28.8,percent of total billed charges,48% of total billed charges,51.73,100,,,fee schedule,100% of bcbs custom fee schedule,51.73,100,,,fee schedule,100% of bcbs custom fee schedule,57.42,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,52.5,70,,42,percent of total billed charges,70% of total billed charges,36.36,48.48,,29.088,percent of total billed charges,48.48% of total billed charges,34.58,116.15,,,fee schedule,116.51% of cms physician fee schedule,36.36,48.48,,29.088,percent of total billed charges,48.48% of total billed charges,52.5,70,,42,percent of total billed charges,70% of total billed charges,52.5,70,,42,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,36.36,48.48,,29.088,percent of total billed charges,48.48% of total billed charges,67.5,90,,54,percent of total billed charges,90% of total billed charges,36.36,90,
ORTHOTIC MGT AND TRAIN OT,48105298,CDM,430,RC,97760,HCPCS,outpatient,,,187,112.20,GO,112.2,60,,89.76,percent of total billed charges,60% of total billed charges,89.76,48,,71.808,percent of total billed charges,48% of total billed charges,69.5,100,,,fee schedule,100% of bcbs custom fee schedule,69.5,100,,,fee schedule,100% of bcbs custom fee schedule,77.15,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,130.9,70,,104.72,percent of total billed charges,70% of total billed charges,90.66,48.48,,72.528,percent of total billed charges,48.48% of total billed charges,50.93,116.15,,,fee schedule,116.51% of cms physician fee schedule,90.66,48.48,,72.528,percent of total billed charges,48.48% of total billed charges,130.9,70,,104.72,percent of total billed charges,70% of total billed charges,130.9,70,,104.72,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,90.66,48.48,,72.528,percent of total billed charges,48.48% of total billed charges,168.3,90,,134.64,percent of total billed charges,90% of total billed charges,48.48,168.3,
ORTHOTIC MGT AND TRAIN PT,48105298,CDM,420,RC,97760,HCPCS,outpatient,,,187,112.20,GO,112.2,60,,89.76,percent of total billed charges,60% of total billed charges,89.76,48,,71.808,percent of total billed charges,48% of total billed charges,69.5,100,,,fee schedule,100% of bcbs custom fee schedule,69.5,100,,,fee schedule,100% of bcbs custom fee schedule,77.15,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,130.9,70,,104.72,percent of total billed charges,70% of total billed charges,90.66,48.48,,72.528,percent of total billed charges,48.48% of total billed charges,50.93,116.15,,,fee schedule,116.51% of cms physician fee schedule,90.66,48.48,,72.528,percent of total billed charges,48.48% of total billed charges,130.9,70,,104.72,percent of total billed charges,70% of total billed charges,130.9,70,,104.72,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,90.66,48.48,,72.528,percent of total billed charges,48.48% of total billed charges,168.3,90,,134.64,percent of total billed charges,90% of total billed charges,48.48,168.3,
VASOPNEUMATIC DEVICES,,,430,RC,97016,HCPCS,outpatient,,,95,57.00,GP,57,60,,45.6,percent of total billed charges,60% of total billed charges,45.6,48,,36.48,percent of total billed charges,48% of total billed charges,25.43,100,,,fee schedule,100% of bcbs custom fee schedule,25.43,100,,,fee schedule,100% of bcbs custom fee schedule,28.23,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,66.5,70,,53.2,percent of total billed charges,70% of total billed charges,46.06,48.48,,36.848,percent of total billed charges,48.48% of total billed charges,12.81,116.15,,,fee schedule,116.51% of cms physician fee schedule,46.06,48.48,,36.848,percent of total billed charges,48.48% of total billed charges,66.5,70,,53.2,percent of total billed charges,70% of total billed charges,66.5,70,,53.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,46.06,48.48,,36.848,percent of total billed charges,48.48% of total billed charges,85.5,90,,68.4,percent of total billed charges,90% of total billed charges,46.06,90,
MECHANICAL TRACTION OT,48105130,CDM,430,RC,97012,HCPCS,outpatient,,,79,47.40,GP,47.4,60,,37.92,percent of total billed charges,60% of total billed charges,37.92,48,,30.336,percent of total billed charges,48% of total billed charges,27.48,100,,,fee schedule,100% of bcbs custom fee schedule,27.48,100,,,fee schedule,100% of bcbs custom fee schedule,30.5,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,55.3,70,,44.24,percent of total billed charges,70% of total billed charges,38.3,48.48,,30.64,percent of total billed charges,48.48% of total billed charges,15.52,116.15,,,fee schedule,116.51% of cms physician fee schedule,38.3,48.48,,30.64,percent of total billed charges,48.48% of total billed charges,55.3,70,,44.24,percent of total billed charges,70% of total billed charges,55.3,70,,44.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,38.3,48.48,,30.64,percent of total billed charges,48.48% of total billed charges,71.1,90,,56.88,percent of total billed charges,90% of total billed charges,38.3,90,
GROUP THERAPY OT,,,430,RC,97150,HCPCS,outpatient,,,51,30.60,,30.6,60,,24.48,percent of total billed charges,60% of total billed charges,24.48,48,,19.584,percent of total billed charges,48% of total billed charges,32.12,100,,,fee schedule,100% of bcbs custom fee schedule,32.12,100,,,fee schedule,100% of bcbs custom fee schedule,35.65,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,35.7,70,,28.56,percent of total billed charges,70% of total billed charges,24.72,48.48,,19.776,percent of total billed charges,48.48% of total billed charges,19.78,116.15,,,fee schedule,116.51% of cms physician fee schedule,24.72,48.48,,19.776,percent of total billed charges,48.48% of total billed charges,35.7,70,,28.56,percent of total billed charges,70% of total billed charges,35.7,70,,28.56,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,24.72,48.48,,19.776,percent of total billed charges,48.48% of total billed charges,45.9,90,,36.72,percent of total billed charges,90% of total billed charges,24.72,90,
OT CONTRAST BATH,48105265,CDM,430,RC,97034,HCPCS,outpatient,,,25,15.00,,15,60,,12,percent of total billed charges,60% of total billed charges,12,48,,9.6,percent of total billed charges,48% of total billed charges,25.78,100,,,fee schedule,100% of bcbs custom fee schedule,25.78,100,,,fee schedule,100% of bcbs custom fee schedule,28.62,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,17.5,70,,14,percent of total billed charges,70% of total billed charges,12.12,48.48,,9.696,percent of total billed charges,48.48% of total billed charges,15.33,116.15,,,fee schedule,116.51% of cms physician fee schedule,12.12,48.48,,9.696,percent of total billed charges,48.48% of total billed charges,17.5,70,,14,percent of total billed charges,70% of total billed charges,17.5,70,,14,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,12.12,48.48,,9.696,percent of total billed charges,48.48% of total billed charges,22.5,90,,18,percent of total billed charges,90% of total billed charges,12.12,90,
OT THERAPEUTIC EXERCISES,48105140,CDM,430,RC,97110,HCPCS,outpatient,,,172,103.20,GO,103.2,60,,82.56,percent of total billed charges,60% of total billed charges,82.56,48,,66.048,percent of total billed charges,48% of total billed charges,51.9,100,,,fee schedule,100% of bcbs custom fee schedule,51.9,100,,,fee schedule,100% of bcbs custom fee schedule,57.61,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,120.4,70,,96.32,percent of total billed charges,70% of total billed charges,83.39,48.48,,66.712,percent of total billed charges,48.48% of total billed charges,32.06,116.15,,,fee schedule,116.51% of cms physician fee schedule,83.39,48.48,,66.712,percent of total billed charges,48.48% of total billed charges,120.4,70,,96.32,percent of total billed charges,70% of total billed charges,120.4,70,,96.32,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,83.39,48.48,,66.712,percent of total billed charges,48.48% of total billed charges,154.8,90,,123.84,percent of total billed charges,90% of total billed charges,48.48,154.8,
SELF-CARE/HOMEMGMT TRAINING EA 15 MINS,48105267,CDM,430,RC,97535,HCPCS,outpatient,,,173,103.80,,103.8,60,,83.04,percent of total billed charges,60% of total billed charges,83.04,48,,66.432,percent of total billed charges,48% of total billed charges,54.88,100,,,fee schedule,100% of bcbs custom fee schedule,54.88,100,,,fee schedule,100% of bcbs custom fee schedule,60.92,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,121.1,70,,96.88,percent of total billed charges,70% of total billed charges,83.87,48.48,,67.096,percent of total billed charges,48.48% of total billed charges,35.45,116.15,,,fee schedule,116.51% of cms physician fee schedule,83.87,48.48,,67.096,percent of total billed charges,48.48% of total billed charges,121.1,70,,96.88,percent of total billed charges,70% of total billed charges,121.1,70,,96.88,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,83.87,48.48,,67.096,percent of total billed charges,48.48% of total billed charges,155.7,90,,124.56,percent of total billed charges,90% of total billed charges,48.48,155.7,
TRMT SP/LANG/VCE/COMM/AUD,48309001,CDM,440,RC,92507,HCPCS,outpatient,,,139,83.40,GN,83.4,60,,66.72,percent of total billed charges,60% of total billed charges,66.72,48,,53.376,percent of total billed charges,48% of total billed charges,188.05,100,,,fee schedule,100% of bcbs custom fee schedule,188.05,100,,,fee schedule,100% of bcbs custom fee schedule,208.74,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,97.3,70,,77.84,percent of total billed charges,70% of total billed charges,67.39,48.48,,53.912,percent of total billed charges,48.48% of total billed charges,84.09,116.15,,,fee schedule,116.51% of cms physician fee schedule,67.39,48.48,,53.912,percent of total billed charges,48.48% of total billed charges,97.3,70,,77.84,percent of total billed charges,70% of total billed charges,97.3,70,,77.84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,67.39,48.48,,53.912,percent of total billed charges,48.48% of total billed charges,125.1,90,,100.08,percent of total billed charges,90% of total billed charges,48.48,125.1,
SPEECH TX OF SWALL/FEED,48105289,CDM,440,RC,92526,HCPCS,outpatient,,,220,132.00,,132,60,,105.6,percent of total billed charges,60% of total billed charges,105.6,48,,84.48,percent of total billed charges,48% of total billed charges,256.74,100,,,fee schedule,100% of bcbs custom fee schedule,256.74,100,,,fee schedule,100% of bcbs custom fee schedule,284.98,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,154,70,,123.2,percent of total billed charges,70% of total billed charges,106.66,48.48,,85.328,percent of total billed charges,48.48% of total billed charges,92.76,116.15,,,fee schedule,116.51% of cms physician fee schedule,106.66,48.48,,85.328,percent of total billed charges,48.48% of total billed charges,154,70,,123.2,percent of total billed charges,70% of total billed charges,154,70,,123.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,106.66,48.48,,85.328,percent of total billed charges,48.48% of total billed charges,198,90,,158.4,percent of total billed charges,90% of total billed charges,48.48,198,
SWALLOWING EVALUATION,48105304,CDM,444,RC,92610,HCPCS,outpatient,,,361,216.60,,216.6,60,,173.28,percent of total billed charges,60% of total billed charges,173.28,48,,138.624,percent of total billed charges,48% of total billed charges,256.61,100,,,fee schedule,100% of bcbs custom fee schedule,256.61,100,,,fee schedule,100% of bcbs custom fee schedule,284.84,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,252.7,70,,202.16,percent of total billed charges,70% of total billed charges,175.01,48.48,,140.008,percent of total billed charges,48.48% of total billed charges,77.76,116.15,,,fee schedule,116.51% of cms physician fee schedule,175.01,48.48,,140.008,percent of total billed charges,48.48% of total billed charges,252.7,70,,202.16,percent of total billed charges,70% of total billed charges,252.7,70,,202.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,175.01,48.48,,140.008,percent of total billed charges,48.48% of total billed charges,324.9,90,,259.92,percent of total billed charges,90% of total billed charges,48.48,324.9,
MOTION FLUORSCOPY/SWAL,,,444,RC,92611,HCPCS,outpatient,,,946.15,567.69,,567.69,60,,454.152,percent of total billed charges,60% of total billed charges,454.15,48,,363.32,percent of total billed charges,48% of total billed charges,381.2,100,,,fee schedule,100% of bcbs custom fee schedule,381.2,100,,,fee schedule,100% of bcbs custom fee schedule,423.13,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,662.31,70,,529.848,percent of total billed charges,70% of total billed charges,458.69,48.48,,366.952,percent of total billed charges,48.48% of total billed charges,100.62,116.15,,,fee schedule,116.51% of cms physician fee schedule,458.69,48.48,,366.952,percent of total billed charges,48.48% of total billed charges,662.31,70,,529.848,percent of total billed charges,70% of total billed charges,662.31,70,,529.848,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,458.69,48.48,,366.952,percent of total billed charges,48.48% of total billed charges,851.54,90,,681.232,percent of total billed charges,90% of total billed charges,48.48,851.54,
Cognskills Deveopment ST,48200128,CDM,440,RC,97129,HCPCS,outpatient,,,131,78.60,,78.6,60,,62.88,percent of total billed charges,60% of total billed charges,62.88,48,,50.304,percent of total billed charges,48% of total billed charges,0.01,100,,,fee schedule,100% of bcbs custom fee schedule,0.01,100,,,fee schedule,100% of bcbs custom fee schedule,0.01,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,91.7,70,,73.36,percent of total billed charges,70% of total billed charges,63.51,48.48,,50.808,percent of total billed charges,48.48% of total billed charges,24.84,116.15,,,fee schedule,116.51% of cms physician fee schedule,63.51,48.48,,50.808,percent of total billed charges,48.48% of total billed charges,91.7,70,,73.36,percent of total billed charges,70% of total billed charges,91.7,70,,73.36,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,63.51,48.48,,50.808,percent of total billed charges,48.48% of total billed charges,117.9,90,,94.32,percent of total billed charges,90% of total billed charges,48.48,117.9,
COGNITIVE FUNC EA. ADD 15 MINS,48200129,CDM,440,RC,97130,HCPCS,outpatient,,,114.95,68.97,,68.97,60,,55.176,percent of total billed charges,60% of total billed charges,55.18,48,,44.144,percent of total billed charges,48% of total billed charges,0.01,100,,,fee schedule,100% of bcbs custom fee schedule,0.01,100,,,fee schedule,100% of bcbs custom fee schedule,0.01,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,80.47,70,,64.376,percent of total billed charges,70% of total billed charges,55.73,48.48,,44.584,percent of total billed charges,48.48% of total billed charges,23.74,116.15,,,fee schedule,116.51% of cms physician fee schedule,55.73,48.48,,44.584,percent of total billed charges,48.48% of total billed charges,80.47,70,,64.376,percent of total billed charges,70% of total billed charges,80.47,70,,64.376,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,55.73,48.48,,44.584,percent of total billed charges,48.48% of total billed charges,103.46,90,,82.768,percent of total billed charges,90% of total billed charges,48.48,103.46,
SPEECH SOUND LANG COMP/EX,48309014,CDM,444,RC,92523,HCPCS,outpatient,,,374,224.40,,224.4,60,,179.52,percent of total billed charges,60% of total billed charges,179.52,48,,143.616,percent of total billed charges,48% of total billed charges,256.69,100,,,fee schedule,100% of bcbs custom fee schedule,256.69,100,,,fee schedule,100% of bcbs custom fee schedule,284.93,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,261.8,70,,209.44,percent of total billed charges,70% of total billed charges,181.32,48.48,,145.056,percent of total billed charges,48.48% of total billed charges,251.1,116.15,,,fee schedule,116.51% of cms physician fee schedule,181.32,48.48,,145.056,percent of total billed charges,48.48% of total billed charges,261.8,70,,209.44,percent of total billed charges,70% of total billed charges,261.8,70,,209.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,181.32,48.48,,145.056,percent of total billed charges,48.48% of total billed charges,336.6,90,,269.28,percent of total billed charges,90% of total billed charges,48.48,336.6,
FLEXIBLE FIBEROPTIC ENDOSCOPIC EVAL,,,440,RC,92612,HCPCS,outpatient,,,223.91,134.35,,134.35,60,,107.48,percent of total billed charges,60% of total billed charges,107.48,48,,85.984,percent of total billed charges,48% of total billed charges,461.23,100,,,fee schedule,100% of bcbs custom fee schedule,461.23,100,,,fee schedule,100% of bcbs custom fee schedule,511.97,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,156.74,70,,125.392,percent of total billed charges,70% of total billed charges,108.55,48.48,,86.84,percent of total billed charges,48.48% of total billed charges,73.43,116.15,,,fee schedule,116.51% of cms physician fee schedule,108.55,48.48,,86.84,percent of total billed charges,48.48% of total billed charges,156.74,70,,125.392,percent of total billed charges,70% of total billed charges,156.74,70,,125.392,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,108.55,48.48,,86.84,percent of total billed charges,48.48% of total billed charges,201.52,90,,161.216,percent of total billed charges,90% of total billed charges,48.48,201.52,
EVAL OF SPEECH FLUENCY,48309012,CDM,440,RC,92521,HCPCS,outpatient,,,127.45,76.47,,76.47,60,,61.176,percent of total billed charges,60% of total billed charges,61.18,48,,48.944,percent of total billed charges,48% of total billed charges,152.11,100,,,fee schedule,100% of bcbs custom fee schedule,152.11,100,,,fee schedule,100% of bcbs custom fee schedule,168.84,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,89.22,70,,71.376,percent of total billed charges,70% of total billed charges,61.79,48.48,,49.432,percent of total billed charges,48.48% of total billed charges,146.49,116.15,,,fee schedule,116.51% of cms physician fee schedule,61.79,48.48,,49.432,percent of total billed charges,48.48% of total billed charges,89.22,70,,71.376,percent of total billed charges,70% of total billed charges,89.22,70,,71.376,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,61.79,48.48,,49.432,percent of total billed charges,48.48% of total billed charges,114.71,90,,91.768,percent of total billed charges,90% of total billed charges,48.48,114.71,
EVAL OF SPEECH SOUND PRODUCTION,48309013,CDM,440,RC,92522,HCPCS,outpatient,,,104.01,62.41,,62.41,60,,49.928,percent of total billed charges,60% of total billed charges,49.92,48,,39.936,percent of total billed charges,48% of total billed charges,123.77,100,,,fee schedule,100% of bcbs custom fee schedule,123.77,100,,,fee schedule,100% of bcbs custom fee schedule,137.38,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,72.81,70,,58.248,percent of total billed charges,70% of total billed charges,50.42,48.48,,40.336,percent of total billed charges,48.48% of total billed charges,123.05,116.15,,,fee schedule,116.51% of cms physician fee schedule,50.42,48.48,,40.336,percent of total billed charges,48.48% of total billed charges,72.81,70,,58.248,percent of total billed charges,70% of total billed charges,72.81,70,,58.248,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,50.42,48.48,,40.336,percent of total billed charges,48.48% of total billed charges,93.61,90,,74.888,percent of total billed charges,90% of total billed charges,48.48,93.61,
STANDARDIZED COGNITIVE PERFORMANCE TEST,48300169,CDM,440,RC,96125,HCPCS,outpatient,,,123.07,73.84,,73.84,60,,59.072,percent of total billed charges,60% of total billed charges,59.07,48,,47.256,percent of total billed charges,48% of total billed charges,289.05,100,,,fee schedule,100% of bcbs custom fee schedule,289.05,100,,,fee schedule,100% of bcbs custom fee schedule,320.85,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,86.15,70,,68.92,percent of total billed charges,70% of total billed charges,59.66,48.48,,47.728,percent of total billed charges,48.48% of total billed charges,112.75,116.15,,,fee schedule,116.51% of cms physician fee schedule,59.66,48.48,,47.728,percent of total billed charges,48.48% of total billed charges,86.15,70,,68.92,percent of total billed charges,70% of total billed charges,86.15,70,,68.92,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,59.66,48.48,,47.728,percent of total billed charges,48.48% of total billed charges,110.76,90,,88.608,percent of total billed charges,90% of total billed charges,48.48,110.76,
EVAL FOR RX FOR SPEECH AAC DEVICE,,,440,RC,92607,HCPCS,outpatient,,,145.3,87.18,,87.18,60,,69.744,percent of total billed charges,60% of total billed charges,69.74,48,,55.792,percent of total billed charges,48% of total billed charges,72.65,50,,58.12,percent of total billed charges,50% of total billed charges,72.65,50,,58.12,percent of total billed charges,50% of total billed charges,72.65,50,,58.12,percent of total billed charges,50% of total billed charges,80,100,,,case rate,pays based on per visit rate,101.71,70,,81.368,percent of total billed charges,70% of total billed charges,70.44,48.48,,56.352,percent of total billed charges,48.48% of total billed charges,135.37,116.15,,,fee schedule,116.51% of cms physician fee schedule,70.44,48.48,,56.352,percent of total billed charges,48.48% of total billed charges,101.71,70,,81.368,percent of total billed charges,70% of total billed charges,101.71,70,,81.368,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,70.44,48.48,,56.352,percent of total billed charges,48.48% of total billed charges,130.77,90,,104.616,percent of total billed charges,90% of total billed charges,48.48,130.77,
THERAPEUTIC SERV FOR USE OF AAC DEVICE,,,440,RC,92609,HCPCS,outpatient,,,122.28,73.37,,73.37,60,,58.696,percent of total billed charges,60% of total billed charges,58.69,48,,46.952,percent of total billed charges,48% of total billed charges,177.07,100,,,fee schedule,100% of bcbs custom fee schedule,177.07,100,,,fee schedule,100% of bcbs custom fee schedule,196.55,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,85.6,70,,68.48,percent of total billed charges,70% of total billed charges,59.28,48.48,,47.424,percent of total billed charges,48.48% of total billed charges,112.6,116.15,,,fee schedule,116.51% of cms physician fee schedule,59.28,48.48,,47.424,percent of total billed charges,48.48% of total billed charges,85.6,70,,68.48,percent of total billed charges,70% of total billed charges,85.6,70,,68.48,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,59.28,48.48,,47.424,percent of total billed charges,48.48% of total billed charges,110.05,90,,88.04,percent of total billed charges,90% of total billed charges,48.48,110.05,
GROUP THERAPY ST,,,440,RC,97150,HCPCS,outpatient,,,51,30.60,,30.6,60,,24.48,percent of total billed charges,60% of total billed charges,24.48,48,,19.584,percent of total billed charges,48% of total billed charges,32.12,100,,,fee schedule,100% of bcbs custom fee schedule,32.12,100,,,fee schedule,100% of bcbs custom fee schedule,35.65,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,35.7,70,,28.56,percent of total billed charges,70% of total billed charges,24.72,48.48,,19.776,percent of total billed charges,48.48% of total billed charges,19.78,116.15,,,fee schedule,116.51% of cms physician fee schedule,24.72,48.48,,19.776,percent of total billed charges,48.48% of total billed charges,35.7,70,,28.56,percent of total billed charges,70% of total billed charges,35.7,70,,28.56,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,24.72,48.48,,19.776,percent of total billed charges,48.48% of total billed charges,45.9,90,,36.72,percent of total billed charges,90% of total billed charges,24.72,90,
NEW PT LVL 2,43600129,CDM,981,RC,99202,HCPCS,outpatient,,,103.48,62.09,,,,,,other,not separately reimbusable,45.66,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,49.19,100,,,fee schedule,100% of cigna custom fee schedule,50.23,110,,,fee schedule,110% of cms physician fee schedule,46.12,101,,,fee schedule,101% of cms physician fee schedule ,46.12,116.15,,,fee schedule,116.51% of cms physician fee schedule,46.12,101,,,fee schedule,101% of cms physician fee schedule,86.75,110,,,fee schedule,110% of humana physician fee schedule,50.23,110,,,fee schedule,110% of humana physician fee schedule,68.49,150,,,fee schedule,100% of cms fee schedule,45.66,100,,,fee schedule,100% of cms physician fee schedule,68.49,150,,,fee schedule,150% of cms physician fee schedule,45.66,150,
OPTH NEW PT LVL 3,43600130,CDM,981,RC,99203,HCPCS,outpatient,,,198.7,119.22,,,,,,other,not separately reimbusable,79.18,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,75,100,,,fee schedule,100% of cigna custom fee schedule,87.1,110,,,fee schedule,110% of cms physician fee schedule,79.97,101,,,fee schedule,101% of cms physician fee schedule ,79.97,116.15,,,fee schedule,116.51% of cms physician fee schedule,79.97,101,,,fee schedule,101% of cms physician fee schedule,150.44,110,,,fee schedule,110% of humana physician fee schedule,87.1,110,,,fee schedule,110% of humana physician fee schedule,118.77,150,,,fee schedule,100% of cms fee schedule,79.18,100,,,fee schedule,100% of cms physician fee schedule,118.77,150,,,fee schedule,150% of cms physician fee schedule,79.18,150,
OPTH NEW PT LVL 4,43600131,CDM,981,RC,99204,HCPCS,outpatient,,,267.88,160.73,,,,,,other,not separately reimbusable,128.63,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,126.59,100,,,fee schedule,100% of cigna custom fee schedule,141.49,110,,,fee schedule,110% of cms physician fee schedule,129.92,101,,,fee schedule,101% of cms physician fee schedule ,129.92,116.15,,,fee schedule,116.51% of cms physician fee schedule,129.92,101,,,fee schedule,101% of cms physician fee schedule,244.4,110,,,fee schedule,110% of humana physician fee schedule,141.49,110,,,fee schedule,110% of humana physician fee schedule,192.95,150,,,fee schedule,100% of cms fee schedule,128.63,100,,,fee schedule,100% of cms physician fee schedule,192.95,150,,,fee schedule,150% of cms physician fee schedule,100,192.95,
NEBULIZER TREATMENT - RT,43102004,CDM,410,RC,94640,HCPCS,outpatient,,,250,150.00,76,150,60,,120,percent of total billed charges,60% of total billed charges,120,48,,96,percent of total billed charges,48% of total billed charges,44.88,100,,,fee schedule,100% of bcbs custom fee schedule,44.88,100,,,fee schedule,100% of bcbs custom fee schedule,49.82,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,175,70,,140,percent of total billed charges,70% of total billed charges,121.2,48.48,,96.96,percent of total billed charges,48.48% of total billed charges,8.22,116.15,,,fee schedule,116.51% of cms physician fee schedule,121.2,48.48,,96.96,percent of total billed charges,48.48% of total billed charges,175,70,,140,percent of total billed charges,70% of total billed charges,175,70,,140,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,121.2,48.48,,96.96,percent of total billed charges,48.48% of total billed charges,225,90,,180,percent of total billed charges,90% of total billed charges,48.48,225,
PULSE OX PER 24 HOURS,43102066,CDM,460,RC,94761,HCPCS,outpatient,,,300,180.00,59,180,60,,144,percent of total billed charges,60% of total billed charges,144,48,,115.2,percent of total billed charges,48% of total billed charges,1.16,100,,,fee schedule,100% of bcbs custom fee schedule,1.16,100,,,fee schedule,100% of bcbs custom fee schedule,1.29,111,,,fee schedule,111% of bcbs custom fee schedule,150,50,,120,percent of total billed charges,50% of total billed charges,210,70,,168,percent of total billed charges,70% of total billed charges,145.44,48.48,,116.352,percent of total billed charges,48.48% of total billed charges,4.16,116.15,,,fee schedule,116.51% of cms physician fee schedule,145.44,48.48,,116.352,percent of total billed charges,48.48% of total billed charges,210,70,,168,percent of total billed charges,70% of total billed charges,210,70,,168,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,145.44,48.48,,116.352,percent of total billed charges,48.48% of total billed charges,270,90,,216,percent of total billed charges,90% of total billed charges,48.48,270,
RT CONSULT/EVAL/REEVAL 15 MINS INCR,,,410,RC,G0238,HCPCS,outpatient,,,187.5,112.50,,112.5,60,,90,percent of total billed charges,60% of total billed charges,90,48,,72,percent of total billed charges,48% of total billed charges,51.36,100,,,fee schedule,100% of bcbs custom fee schedule,51.36,100,,,fee schedule,100% of bcbs custom fee schedule,57.01,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,131.25,70,,105,percent of total billed charges,70% of total billed charges,90.9,48.48,,72.72,percent of total billed charges,48.48% of total billed charges,10.59,116.15,,,fee schedule,116.51% of cms physician fee schedule,90.9,48.48,,72.72,percent of total billed charges,48.48% of total billed charges,131.25,70,,105,percent of total billed charges,70% of total billed charges,131.25,70,,105,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,90.9,48.48,,72.72,percent of total billed charges,48.48% of total billed charges,168.75,90,,135,percent of total billed charges,90% of total billed charges,48.48,168.75,
BIPAP/CPAP PROCEDURE,43102055,CDM,410,RC,94660,HCPCS,outpatient,,,437.5,262.50,,262.5,60,,210,percent of total billed charges,60% of total billed charges,210,48,,168,percent of total billed charges,48% of total billed charges,162.81,100,,,fee schedule,100% of bcbs custom fee schedule,162.81,100,,,fee schedule,100% of bcbs custom fee schedule,180.72,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,306.25,70,,245,percent of total billed charges,70% of total billed charges,212.1,48.48,,169.68,percent of total billed charges,48.48% of total billed charges,41.51,116.15,,,fee schedule,116.51% of cms physician fee schedule,212.1,48.48,,169.68,percent of total billed charges,48.48% of total billed charges,306.25,70,,245,percent of total billed charges,70% of total billed charges,306.25,70,,245,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,212.1,48.48,,169.68,percent of total billed charges,48.48% of total billed charges,393.75,90,,315,percent of total billed charges,90% of total billed charges,48.48,393.75,
DEMO/EVAL USE OF INHAL - RT,43102005,CDM,410,RC,94664,HCPCS,outpatient,,,312.5,187.50,,187.5,60,,150,percent of total billed charges,60% of total billed charges,150,48,,120,percent of total billed charges,48% of total billed charges,44.88,100,,,fee schedule,100% of bcbs custom fee schedule,44.88,100,,,fee schedule,100% of bcbs custom fee schedule,49.82,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,218.75,70,,175,percent of total billed charges,70% of total billed charges,151.5,48.48,,121.2,percent of total billed charges,48.48% of total billed charges,18.49,116.15,,,fee schedule,116.51% of cms physician fee schedule,151.5,48.48,,121.2,percent of total billed charges,48.48% of total billed charges,218.75,70,,175,percent of total billed charges,70% of total billed charges,218.75,70,,175,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,151.5,48.48,,121.2,percent of total billed charges,48.48% of total billed charges,281.25,90,,225,percent of total billed charges,90% of total billed charges,48.48,281.25,
"CANNULA, NASAL, ADULT",,,270,RC,A4615,HCPCS,outpatient,,,16.94,10.16,,10.16,60,,8.128,percent of total billed charges,60% of total billed charges,8.13,48,,6.504,percent of total billed charges,48% of total billed charges,8.47,50,,6.776,percent of total billed charges,50% of total billed charges,8.47,50,,6.776,percent of total billed charges,50% of total billed charges,8.47,50,,6.776,percent of total billed charges,50% of total billed charges,8.47,50,,6.776,percent of total billed charges,50% of total billed charges,11.86,70,,9.488,percent of total billed charges,70% of total billed charges,8.21,48.48,,6.568,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,8.21,48.48,,6.568,percent of total billed charges,48.48% of total billed charges,11.86,70,,9.488,percent of total billed charges,70% of total billed charges,11.86,70,,9.488,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,8.21,48.48,,6.568,percent of total billed charges,48.48% of total billed charges,15.25,90,,12.2,percent of total billed charges,90% of total billed charges,8.21,90,
NASAL CATHETER-O2,,,270,RC,,,outpatient,,,10.44,6.26,,6.26,60,,5.008,percent of total billed charges,60% of total billed charges,5.01,48,,4.008,percent of total billed charges,48% of total billed charges,5.22,50,,4.176,percent of total billed charges,50% of total billed charges,5.22,50,,4.176,percent of total billed charges,50% of total billed charges,5.22,50,,4.176,percent of total billed charges,50% of total billed charges,5.22,50,,4.176,percent of total billed charges,50% of total billed charges,7.31,70,,5.848,percent of total billed charges,70% of total billed charges,5.06,48.48,,4.048,percent of total billed charges,48.48% of total billed charges,5.06,48.48,,4.048,percent of total billed charges,48.48% of total billed charges,5.06,48.48,,4.048,percent of total billed charges,48.48% of total billed charges,7.31,70,,5.848,percent of total billed charges,70% of total billed charges,7.31,70,,5.848,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,5.06,48.48,,4.048,percent of total billed charges,48.48% of total billed charges,9.4,90,,7.52,percent of total billed charges,90% of total billed charges,5.06,90,
"OXYGEN SIMPLE MASK, ADULT",,,270,RC,A4620,HCPCS,outpatient,,,18.15,10.89,,10.89,60,,8.712,percent of total billed charges,60% of total billed charges,8.71,48,,6.968,percent of total billed charges,48% of total billed charges,9.08,50,,7.264,percent of total billed charges,50% of total billed charges,9.08,50,,7.264,percent of total billed charges,50% of total billed charges,9.08,50,,7.264,percent of total billed charges,50% of total billed charges,9.08,50,,7.264,percent of total billed charges,50% of total billed charges,12.71,70,,10.168,percent of total billed charges,70% of total billed charges,8.8,48.48,,7.04,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,8.8,48.48,,7.04,percent of total billed charges,48.48% of total billed charges,12.71,70,,10.168,percent of total billed charges,70% of total billed charges,12.71,70,,10.168,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,8.8,48.48,,7.04,percent of total billed charges,48.48% of total billed charges,16.34,90,,13.072,percent of total billed charges,90% of total billed charges,8.8,90,
"OXYGEN SIMPLE MASK, PEDIATRIC",,,270,RC,A4620,HCPCS,outpatient,,,16.28,9.77,,9.77,60,,7.816,percent of total billed charges,60% of total billed charges,7.81,48,,6.248,percent of total billed charges,48% of total billed charges,8.14,50,,6.512,percent of total billed charges,50% of total billed charges,8.14,50,,6.512,percent of total billed charges,50% of total billed charges,8.14,50,,6.512,percent of total billed charges,50% of total billed charges,8.14,50,,6.512,percent of total billed charges,50% of total billed charges,11.4,70,,9.12,percent of total billed charges,70% of total billed charges,7.89,48.48,,6.312,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,7.89,48.48,,6.312,percent of total billed charges,48.48% of total billed charges,11.4,70,,9.12,percent of total billed charges,70% of total billed charges,11.4,70,,9.12,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,7.89,48.48,,6.312,percent of total billed charges,48.48% of total billed charges,14.65,90,,11.72,percent of total billed charges,90% of total billed charges,7.89,90,
"OXYGEN SIMPLE MASK, INFANT",,,270,RC,A4620,HCPCS,outpatient,,,25.63,15.38,,15.38,60,,12.304,percent of total billed charges,60% of total billed charges,12.3,48,,9.84,percent of total billed charges,48% of total billed charges,12.82,50,,10.256,percent of total billed charges,50% of total billed charges,12.82,50,,10.256,percent of total billed charges,50% of total billed charges,12.82,50,,10.256,percent of total billed charges,50% of total billed charges,12.82,50,,10.256,percent of total billed charges,50% of total billed charges,17.94,70,,14.352,percent of total billed charges,70% of total billed charges,12.43,48.48,,9.944,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,12.43,48.48,,9.944,percent of total billed charges,48.48% of total billed charges,17.94,70,,14.352,percent of total billed charges,70% of total billed charges,17.94,70,,14.352,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,12.43,48.48,,9.944,percent of total billed charges,48.48% of total billed charges,23.07,90,,18.456,percent of total billed charges,90% of total billed charges,12.43,90,
STERILE WATER-INHALATION,,,270,RC,,,outpatient,,,18.15,10.89,,10.89,60,,8.712,percent of total billed charges,60% of total billed charges,8.71,48,,6.968,percent of total billed charges,48% of total billed charges,9.08,50,,7.264,percent of total billed charges,50% of total billed charges,9.08,50,,7.264,percent of total billed charges,50% of total billed charges,9.08,50,,7.264,percent of total billed charges,50% of total billed charges,9.08,50,,7.264,percent of total billed charges,50% of total billed charges,12.71,70,,10.168,percent of total billed charges,70% of total billed charges,8.8,48.48,,7.04,percent of total billed charges,48.48% of total billed charges,8.8,48.48,,7.04,percent of total billed charges,48.48% of total billed charges,8.8,48.48,,7.04,percent of total billed charges,48.48% of total billed charges,12.71,70,,10.168,percent of total billed charges,70% of total billed charges,12.71,70,,10.168,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,8.8,48.48,,7.04,percent of total billed charges,48.48% of total billed charges,16.34,90,,13.072,percent of total billed charges,90% of total billed charges,8.8,90,
DISP NEBULIZER SET-UP,,,270,RC,,,outpatient,,,30.25,18.15,,18.15,60,,14.52,percent of total billed charges,60% of total billed charges,14.52,48,,11.616,percent of total billed charges,48% of total billed charges,15.13,50,,12.104,percent of total billed charges,50% of total billed charges,15.13,50,,12.104,percent of total billed charges,50% of total billed charges,15.13,50,,12.104,percent of total billed charges,50% of total billed charges,15.13,50,,12.104,percent of total billed charges,50% of total billed charges,21.18,70,,16.944,percent of total billed charges,70% of total billed charges,14.67,48.48,,11.736,percent of total billed charges,48.48% of total billed charges,14.67,48.48,,11.736,percent of total billed charges,48.48% of total billed charges,14.67,48.48,,11.736,percent of total billed charges,48.48% of total billed charges,21.18,70,,16.944,percent of total billed charges,70% of total billed charges,21.18,70,,16.944,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,14.67,48.48,,11.736,percent of total billed charges,48.48% of total billed charges,27.23,90,,21.784,percent of total billed charges,90% of total billed charges,14.67,90,
"NON-REBREATHER MASK, ADULT",,,270,RC,A4620,HCPCS,outpatient,,,19.36,11.62,,11.62,60,,9.296,percent of total billed charges,60% of total billed charges,9.29,48,,7.432,percent of total billed charges,48% of total billed charges,9.68,50,,7.744,percent of total billed charges,50% of total billed charges,9.68,50,,7.744,percent of total billed charges,50% of total billed charges,9.68,50,,7.744,percent of total billed charges,50% of total billed charges,9.68,50,,7.744,percent of total billed charges,50% of total billed charges,13.55,70,,10.84,percent of total billed charges,70% of total billed charges,9.39,48.48,,7.512,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.39,48.48,,7.512,percent of total billed charges,48.48% of total billed charges,13.55,70,,10.84,percent of total billed charges,70% of total billed charges,13.55,70,,10.84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.39,48.48,,7.512,percent of total billed charges,48.48% of total billed charges,17.42,90,,13.936,percent of total billed charges,90% of total billed charges,9.39,90,
"NON-REBREATHER MASK, PEDIATRIC",,,270,RC,A4620,HCPCS,outpatient,,,25.74,15.44,,15.44,60,,12.352,percent of total billed charges,60% of total billed charges,12.36,48,,9.888,percent of total billed charges,48% of total billed charges,12.87,50,,10.296,percent of total billed charges,50% of total billed charges,12.87,50,,10.296,percent of total billed charges,50% of total billed charges,12.87,50,,10.296,percent of total billed charges,50% of total billed charges,12.87,50,,10.296,percent of total billed charges,50% of total billed charges,18.02,70,,14.416,percent of total billed charges,70% of total billed charges,12.48,48.48,,9.984,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,12.48,48.48,,9.984,percent of total billed charges,48.48% of total billed charges,18.02,70,,14.416,percent of total billed charges,70% of total billed charges,18.02,70,,14.416,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,12.48,48.48,,9.984,percent of total billed charges,48.48% of total billed charges,23.17,90,,18.536,percent of total billed charges,90% of total billed charges,12.48,90,
OXYGEN PER DAY,,,410,RC,,,outpatient,,,223.85,134.31,,134.31,60,,107.448,percent of total billed charges,60% of total billed charges,107.45,48,,85.96,percent of total billed charges,48% of total billed charges,111.93,50,,89.544,percent of total billed charges,50% of total billed charges,111.93,50,,89.544,percent of total billed charges,50% of total billed charges,111.93,50,,89.544,percent of total billed charges,50% of total billed charges,80,100,,,case rate,pays based on per visit rate,156.7,70,,125.36,percent of total billed charges,70% of total billed charges,108.52,48.48,,86.816,percent of total billed charges,48.48% of total billed charges,108.52,48.48,,86.816,percent of total billed charges,48.48% of total billed charges,108.52,48.48,,86.816,percent of total billed charges,48.48% of total billed charges,156.7,70,,125.36,percent of total billed charges,70% of total billed charges,156.7,70,,125.36,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,108.52,48.48,,86.816,percent of total billed charges,48.48% of total billed charges,201.47,90,,161.176,percent of total billed charges,90% of total billed charges,48.48,201.47,
OXYGEN SUPPLIES,,,270,RC,,,outpatient,,,36.3,21.78,,21.78,60,,17.424,percent of total billed charges,60% of total billed charges,17.42,48,,13.936,percent of total billed charges,48% of total billed charges,18.15,50,,14.52,percent of total billed charges,50% of total billed charges,18.15,50,,14.52,percent of total billed charges,50% of total billed charges,18.15,50,,14.52,percent of total billed charges,50% of total billed charges,18.15,50,,14.52,percent of total billed charges,50% of total billed charges,25.41,70,,20.328,percent of total billed charges,70% of total billed charges,17.6,48.48,,14.08,percent of total billed charges,48.48% of total billed charges,17.6,48.48,,14.08,percent of total billed charges,48.48% of total billed charges,17.6,48.48,,14.08,percent of total billed charges,48.48% of total billed charges,25.41,70,,20.328,percent of total billed charges,70% of total billed charges,25.41,70,,20.328,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,17.6,48.48,,14.08,percent of total billed charges,48.48% of total billed charges,32.67,90,,26.136,percent of total billed charges,90% of total billed charges,17.6,90,
EXERCISE TEST W/O ECG,,,410,RC,94619,HCPCS,outpatient,,,128,76.80,,76.8,60,,61.44,percent of total billed charges,60% of total billed charges,61.44,48,,49.152,percent of total billed charges,48% of total billed charges,64,50,,51.2,percent of total billed charges,50% of total billed charges,64,50,,51.2,percent of total billed charges,50% of total billed charges,64,50,,51.2,percent of total billed charges,50% of total billed charges,80,100,,,case rate,pays based on per visit rate,89.6,70,,71.68,percent of total billed charges,70% of total billed charges,62.05,48.48,,49.64,percent of total billed charges,48.48% of total billed charges,68.7,116.15,,,fee schedule,116.51% of cms physician fee schedule,62.05,48.48,,49.64,percent of total billed charges,48.48% of total billed charges,89.6,70,,71.68,percent of total billed charges,70% of total billed charges,89.6,70,,71.68,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,62.05,48.48,,49.64,percent of total billed charges,48.48% of total billed charges,115.2,90,,92.16,percent of total billed charges,90% of total billed charges,48.48,115.2,
OUTPT VISIT MIN EST,32000200,CDM,761,RC,99211,HCPCS,outpatient,,,306.36,183.82,,183.82,60,,147.056,percent of total billed charges,60% of total billed charges,147.05,48,,117.64,percent of total billed charges,48% of total billed charges,115.22,100,,,fee schedule,100% of bcbs custom fee schedule,115.22,100,,,fee schedule,100% of bcbs custom fee schedule,127.89,111,,,fee schedule,111% of bcbs custom fee schedule,153.18,50,,122.544,percent of total billed charges,50% of total billed charges,214.45,70,,171.56,percent of total billed charges,70% of total billed charges,148.52,48.48,,118.816,percent of total billed charges,48.48% of total billed charges,9.77,116.15,,,fee schedule,116.51% of cms physician fee schedule,148.52,48.48,,118.816,percent of total billed charges,48.48% of total billed charges,214.45,70,,171.56,percent of total billed charges,70% of total billed charges,214.45,70,,171.56,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,148.52,48.48,,118.816,percent of total billed charges,48.48% of total billed charges,275.72,90,,220.576,percent of total billed charges,90% of total billed charges,48.48,275.72,
PLCMT GASTROSTOMY TUBE,,,761,RC,43246,HCPCS,outpatient,,,6445.3,3867.18,,535,100,,,fee schedule,100% of asc tier groupings rate,3093.74,48,,2474.992,percent of total billed charges,48% of total billed charges,1311.86,100,,,fee schedule,100% of bcbs custom fee schedule,1311.86,100,,,fee schedule,100% of bcbs custom fee schedule,1456.16,111,,,fee schedule,111% of bcbs custom fee schedule,3222.65,50,,2578.12,percent of total billed charges,50% of total billed charges,4511.71,70,,3609.368,percent of total billed charges,70% of total billed charges,3124.68,48.48,,2499.744,percent of total billed charges,48.48% of total billed charges,223.26,116.15,,,fee schedule,116.51% of cms physician fee schedule,3124.68,48.48,,2499.744,percent of total billed charges,48.48% of total billed charges,4511.71,70,,3609.368,percent of total billed charges,70% of total billed charges,4511.71,70,,3609.368,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,3124.68,48.48,,2499.744,percent of total billed charges,48.48% of total billed charges,5800.77,90,,4640.616,percent of total billed charges,90% of total billed charges,48.48,5800.77,
EXC B9 LES T/N/L 0.6-1.0,43600198,CDM,761,RC,11401,HCPCS,outpatient,,,588.75,353.25,,399,100,,,fee schedule,100% of asc tier groupings rate,282.6,48,,226.08,percent of total billed charges,48% of total billed charges,674.63,100,,,fee schedule,100% of bcbs custom fee schedule,674.63,100,,,fee schedule,100% of bcbs custom fee schedule,748.84,111,,,fee schedule,111% of bcbs custom fee schedule,294.38,50,,235.504,percent of total billed charges,50% of total billed charges,412.13,70,,329.704,percent of total billed charges,70% of total billed charges,285.43,48.48,,228.344,percent of total billed charges,48.48% of total billed charges,115.84,116.15,,,fee schedule,116.51% of cms physician fee schedule,285.43,48.48,,228.344,percent of total billed charges,48.48% of total billed charges,412.13,70,,329.704,percent of total billed charges,70% of total billed charges,412.13,70,,329.704,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,285.43,48.48,,228.344,percent of total billed charges,48.48% of total billed charges,529.88,90,,423.904,percent of total billed charges,90% of total billed charges,48.48,529.88,
INJECTION IM/SQ,32004016,CDM,259,RC,96372,HCPCS,outpatient,,,45,27.00,,27,60,,21.6,percent of total billed charges,60% of total billed charges,21.6,48,,17.28,percent of total billed charges,48% of total billed charges,51.29,100,,,fee schedule,100% of bcbs custom fee schedule,51.29,100,,,fee schedule,100% of bcbs custom fee schedule,56.93,111,,,fee schedule,111% of bcbs custom fee schedule,22.5,50,,18,percent of total billed charges,50% of total billed charges,31.5,70,,25.2,percent of total billed charges,70% of total billed charges,21.82,48.48,,17.456,percent of total billed charges,48.48% of total billed charges,15.47,116.15,,,fee schedule,116.51% of cms physician fee schedule,21.82,48.48,,17.456,percent of total billed charges,48.48% of total billed charges,31.5,70,,25.2,percent of total billed charges,70% of total billed charges,31.5,70,,25.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,21.82,48.48,,17.456,percent of total billed charges,48.48% of total billed charges,40.5,90,,32.4,percent of total billed charges,90% of total billed charges,21.82,90,
OUTPT VISIT-2 FACILITY ES,43600141,CDM,761,RC,99212,HCPCS,outpatient,,,306.36,183.82,,183.82,60,,147.056,percent of total billed charges,60% of total billed charges,147.05,48,,117.64,percent of total billed charges,48% of total billed charges,115.22,100,,,fee schedule,100% of bcbs custom fee schedule,115.22,100,,,fee schedule,100% of bcbs custom fee schedule,127.89,111,,,fee schedule,111% of bcbs custom fee schedule,153.18,50,,122.544,percent of total billed charges,50% of total billed charges,214.45,70,,171.56,percent of total billed charges,70% of total billed charges,148.52,48.48,,118.816,percent of total billed charges,48.48% of total billed charges,39.54,116.15,,,fee schedule,116.51% of cms physician fee schedule,148.52,48.48,,118.816,percent of total billed charges,48.48% of total billed charges,214.45,70,,171.56,percent of total billed charges,70% of total billed charges,214.45,70,,171.56,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,148.52,48.48,,118.816,percent of total billed charges,48.48% of total billed charges,275.72,90,,220.576,percent of total billed charges,90% of total billed charges,48.48,275.72,
OUTPT VISIT NEW MINOR 20 MIN,43600129,CDM,761,RC,99202,HCPCS,outpatient,,,331.89,199.13,,199.13,60,,159.304,percent of total billed charges,60% of total billed charges,159.31,48,,127.448,percent of total billed charges,48% of total billed charges,115.22,100,,,fee schedule,100% of bcbs custom fee schedule,115.22,100,,,fee schedule,100% of bcbs custom fee schedule,127.89,111,,,fee schedule,111% of bcbs custom fee schedule,165.95,50,,132.76,percent of total billed charges,50% of total billed charges,232.32,70,,185.856,percent of total billed charges,70% of total billed charges,160.9,48.48,,128.72,percent of total billed charges,48.48% of total billed charges,53.03,116.15,,,fee schedule,116.51% of cms physician fee schedule,160.9,48.48,,128.72,percent of total billed charges,48.48% of total billed charges,232.32,70,,185.856,percent of total billed charges,70% of total billed charges,232.32,70,,185.856,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,160.9,48.48,,128.72,percent of total billed charges,48.48% of total billed charges,298.7,90,,238.96,percent of total billed charges,90% of total billed charges,48.48,298.7,
OUTPT VISIT-3 FACILITY ES,43600142,CDM,761,RC,99213,HCPCS,outpatient,,,331.89,199.13,,199.13,60,,159.304,percent of total billed charges,60% of total billed charges,159.31,48,,127.448,percent of total billed charges,48% of total billed charges,132.57,100,,,fee schedule,100% of bcbs custom fee schedule,132.57,100,,,fee schedule,100% of bcbs custom fee schedule,147.15,111,,,fee schedule,111% of bcbs custom fee schedule,165.95,50,,132.76,percent of total billed charges,50% of total billed charges,232.32,70,,185.856,percent of total billed charges,70% of total billed charges,160.9,48.48,,128.72,percent of total billed charges,48.48% of total billed charges,73.65,116.15,,,fee schedule,116.51% of cms physician fee schedule,160.9,48.48,,128.72,percent of total billed charges,48.48% of total billed charges,232.32,70,,185.856,percent of total billed charges,70% of total billed charges,232.32,70,,185.856,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,160.9,48.48,,128.72,percent of total billed charges,48.48% of total billed charges,298.7,90,,238.96,percent of total billed charges,90% of total billed charges,48.48,298.7,
OUTPT VISIT LOW 30 MIN,43600130,CDM,761,RC,99203,HCPCS,outpatient,,,357.42,214.45,,214.45,60,,171.56,percent of total billed charges,60% of total billed charges,171.56,48,,137.248,percent of total billed charges,48% of total billed charges,132.57,100,,,fee schedule,100% of bcbs custom fee schedule,132.57,100,,,fee schedule,100% of bcbs custom fee schedule,147.15,111,,,fee schedule,111% of bcbs custom fee schedule,178.71,50,,142.968,percent of total billed charges,50% of total billed charges,250.19,70,,200.152,percent of total billed charges,70% of total billed charges,173.28,48.48,,138.624,percent of total billed charges,48.48% of total billed charges,91.97,116.15,,,fee schedule,116.51% of cms physician fee schedule,173.28,48.48,,138.624,percent of total billed charges,48.48% of total billed charges,250.19,70,,200.152,percent of total billed charges,70% of total billed charges,250.19,70,,200.152,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,173.28,48.48,,138.624,percent of total billed charges,48.48% of total billed charges,321.68,90,,257.344,percent of total billed charges,90% of total billed charges,48.48,321.68,
OUTPT VISIT-4 FACILITY ES,43600143,CDM,761,RC,99214,HCPCS,outpatient,,,357.42,214.45,,214.45,60,,171.56,percent of total billed charges,60% of total billed charges,171.56,48,,137.248,percent of total billed charges,48% of total billed charges,192.89,100,,,fee schedule,100% of bcbs custom fee schedule,192.89,100,,,fee schedule,100% of bcbs custom fee schedule,214.11,111,,,fee schedule,111% of bcbs custom fee schedule,178.71,50,,142.968,percent of total billed charges,50% of total billed charges,250.19,70,,200.152,percent of total billed charges,70% of total billed charges,173.28,48.48,,138.624,percent of total billed charges,48.48% of total billed charges,108.53,116.15,,,fee schedule,116.51% of cms physician fee schedule,173.28,48.48,,138.624,percent of total billed charges,48.48% of total billed charges,250.19,70,,200.152,percent of total billed charges,70% of total billed charges,250.19,70,,200.152,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,173.28,48.48,,138.624,percent of total billed charges,48.48% of total billed charges,321.68,90,,257.344,percent of total billed charges,90% of total billed charges,48.48,321.68,
OUTPT VISIT HIGH 45MIN,43600131,CDM,761,RC,99204,HCPCS,outpatient,,,382.95,229.77,,229.77,60,,183.816,percent of total billed charges,60% of total billed charges,183.82,48,,147.056,percent of total billed charges,48% of total billed charges,192.89,100,,,fee schedule,100% of bcbs custom fee schedule,192.89,100,,,fee schedule,100% of bcbs custom fee schedule,214.11,111,,,fee schedule,111% of bcbs custom fee schedule,191.48,50,,153.184,percent of total billed charges,50% of total billed charges,268.07,70,,214.456,percent of total billed charges,70% of total billed charges,185.65,48.48,,148.52,percent of total billed charges,48.48% of total billed charges,149.4,116.15,,,fee schedule,116.51% of cms physician fee schedule,185.65,48.48,,148.52,percent of total billed charges,48.48% of total billed charges,268.07,70,,214.456,percent of total billed charges,70% of total billed charges,268.07,70,,214.456,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,185.65,48.48,,148.52,percent of total billed charges,48.48% of total billed charges,344.66,90,,275.728,percent of total billed charges,90% of total billed charges,48.48,344.66,
OUTPT VISIT-5 FACILITY ES,43600144,CDM,761,RC,99215,HCPCS,outpatient,,,357.42,214.45,,214.45,60,,171.56,percent of total billed charges,60% of total billed charges,171.56,48,,137.248,percent of total billed charges,48% of total billed charges,192.89,100,,,fee schedule,100% of bcbs custom fee schedule,192.89,100,,,fee schedule,100% of bcbs custom fee schedule,214.11,111,,,fee schedule,111% of bcbs custom fee schedule,178.71,50,,142.968,percent of total billed charges,50% of total billed charges,250.19,70,,200.152,percent of total billed charges,70% of total billed charges,173.28,48.48,,138.624,percent of total billed charges,48.48% of total billed charges,161,116.15,,,fee schedule,116.51% of cms physician fee schedule,173.28,48.48,,138.624,percent of total billed charges,48.48% of total billed charges,250.19,70,,200.152,percent of total billed charges,70% of total billed charges,250.19,70,,200.152,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,173.28,48.48,,138.624,percent of total billed charges,48.48% of total billed charges,321.68,90,,257.344,percent of total billed charges,90% of total billed charges,48.48,321.68,
OUTPT VISIT HIGH 60MIN,43600132,CDM,761,RC,99205,HCPCS,outpatient,,,382.95,229.77,,229.77,60,,183.816,percent of total billed charges,60% of total billed charges,183.82,48,,147.056,percent of total billed charges,48% of total billed charges,192.89,100,,,fee schedule,100% of bcbs custom fee schedule,192.89,100,,,fee schedule,100% of bcbs custom fee schedule,214.11,111,,,fee schedule,111% of bcbs custom fee schedule,191.48,50,,153.184,percent of total billed charges,50% of total billed charges,268.07,70,,214.456,percent of total billed charges,70% of total billed charges,185.65,48.48,,148.52,percent of total billed charges,48.48% of total billed charges,203.09,116.15,,,fee schedule,116.51% of cms physician fee schedule,185.65,48.48,,148.52,percent of total billed charges,48.48% of total billed charges,268.07,70,,214.456,percent of total billed charges,70% of total billed charges,268.07,70,,214.456,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,185.65,48.48,,148.52,percent of total billed charges,48.48% of total billed charges,344.66,90,,275.728,percent of total billed charges,90% of total billed charges,48.48,344.66,
CMPLX REP F/G/H/F;1.1-2.5,36010136,CDM,761,RC,13131,HCPCS,outpatient,,,352,211.20,,535,100,,,fee schedule,100% of asc tier groupings rate,168.96,48,,135.168,percent of total billed charges,48% of total billed charges,176,50,,140.8,percent of total billed charges,50% of total billed charges,176,50,,140.8,percent of total billed charges,50% of total billed charges,176,50,,140.8,percent of total billed charges,50% of total billed charges,176,50,,140.8,percent of total billed charges,50% of total billed charges,246.4,70,,197.12,percent of total billed charges,70% of total billed charges,170.65,48.48,,136.52,percent of total billed charges,48.48% of total billed charges,266.84,116.15,,,fee schedule,116.51% of cms physician fee schedule,170.65,48.48,,136.52,percent of total billed charges,48.48% of total billed charges,246.4,70,,197.12,percent of total billed charges,70% of total billed charges,246.4,70,,197.12,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,170.65,48.48,,136.52,percent of total billed charges,48.48% of total billed charges,316.8,90,,253.44,percent of total billed charges,90% of total billed charges,48.48,316.8,
EXC WDGE NAIL FOLD,36013011,CDM,761,RC,11765,HCPCS,outpatient,,,126.25,75.75,,399,100,,,fee schedule,100% of asc tier groupings rate,60.6,48,,48.48,percent of total billed charges,48% of total billed charges,265.71,100,,,fee schedule,100% of bcbs custom fee schedule,265.71,100,,,fee schedule,100% of bcbs custom fee schedule,294.94,111,,,fee schedule,111% of bcbs custom fee schedule,63.13,50,,50.504,percent of total billed charges,50% of total billed charges,88.38,70,,70.704,percent of total billed charges,70% of total billed charges,61.21,48.48,,48.968,percent of total billed charges,48.48% of total billed charges,101.71,116.15,,,fee schedule,116.51% of cms physician fee schedule,61.21,48.48,,48.968,percent of total billed charges,48.48% of total billed charges,88.38,70,,70.704,percent of total billed charges,70% of total billed charges,88.38,70,,70.704,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,61.21,48.48,,48.968,percent of total billed charges,48.48% of total billed charges,113.63,90,,90.904,percent of total billed charges,90% of total billed charges,48.48,113.63,
BX/ EXC LYMPH NODE SUPERF,42001073,CDM,761,RC,38505,HCPCS,outpatient,,,982.5,589.50,,399,100,,,fee schedule,100% of asc tier groupings rate,471.6,48,,377.28,percent of total billed charges,48% of total billed charges,582.79,100,,,fee schedule,100% of bcbs custom fee schedule,582.79,100,,,fee schedule,100% of bcbs custom fee schedule,646.9,111,,,fee schedule,111% of bcbs custom fee schedule,491.25,50,,393,percent of total billed charges,50% of total billed charges,687.75,70,,550.2,percent of total billed charges,70% of total billed charges,476.32,48.48,,381.056,percent of total billed charges,48.48% of total billed charges,94.96,116.15,,,fee schedule,116.51% of cms physician fee schedule,476.32,48.48,,381.056,percent of total billed charges,48.48% of total billed charges,687.75,70,,550.2,percent of total billed charges,70% of total billed charges,687.75,70,,550.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,476.32,48.48,,381.056,percent of total billed charges,48.48% of total billed charges,884.25,90,,707.4,percent of total billed charges,90% of total billed charges,48.48,884.25,
BX OF MOUTH LESION,,,761,RC,40808,HCPCS,outpatient,,,150,90.00,,399,100,,,fee schedule,100% of asc tier groupings rate,72,48,,57.6,percent of total billed charges,48% of total billed charges,338.1,100,,,fee schedule,100% of bcbs custom fee schedule,338.1,100,,,fee schedule,100% of bcbs custom fee schedule,375.29,111,,,fee schedule,111% of bcbs custom fee schedule,75,50,,60,percent of total billed charges,50% of total billed charges,105,70,,84,percent of total billed charges,70% of total billed charges,72.72,48.48,,58.176,percent of total billed charges,48.48% of total billed charges,97.48,116.15,,,fee schedule,116.51% of cms physician fee schedule,72.72,48.48,,58.176,percent of total billed charges,48.48% of total billed charges,105,70,,84,percent of total billed charges,70% of total billed charges,105,70,,84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,72.72,48.48,,58.176,percent of total billed charges,48.48% of total billed charges,135,90,,108,percent of total billed charges,90% of total billed charges,48.48,135,
REMOVE SKIN TAG EA ADD,43600288,CDM,761,RC,11201,HCPCS,outpatient,,,126.25,75.75,,75.75,60,,60.6,percent of total billed charges,60% of total billed charges,60.6,48,,48.48,percent of total billed charges,48% of total billed charges,265.71,100,,,fee schedule,100% of bcbs custom fee schedule,265.71,100,,,fee schedule,100% of bcbs custom fee schedule,294.94,111,,,fee schedule,111% of bcbs custom fee schedule,63.13,50,,50.504,percent of total billed charges,50% of total billed charges,88.38,70,,70.704,percent of total billed charges,70% of total billed charges,61.21,48.48,,48.968,percent of total billed charges,48.48% of total billed charges,17.96,116.15,,,fee schedule,116.51% of cms physician fee schedule,61.21,48.48,,48.968,percent of total billed charges,48.48% of total billed charges,88.38,70,,70.704,percent of total billed charges,70% of total billed charges,88.38,70,,70.704,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,61.21,48.48,,48.968,percent of total billed charges,48.48% of total billed charges,113.63,90,,90.904,percent of total billed charges,90% of total billed charges,48.48,113.63,
SHAVE SKN LES 1.1-2.0,43601701,CDM,761,RC,11302,HCPCS,outpatient,,,126.25,75.75,,75.75,60,,60.6,percent of total billed charges,60% of total billed charges,60.6,48,,48.48,percent of total billed charges,48% of total billed charges,172.44,100,,,fee schedule,100% of bcbs custom fee schedule,172.44,100,,,fee schedule,100% of bcbs custom fee schedule,191.41,111,,,fee schedule,111% of bcbs custom fee schedule,63.13,50,,50.504,percent of total billed charges,50% of total billed charges,88.38,70,,70.704,percent of total billed charges,70% of total billed charges,61.21,48.48,,48.968,percent of total billed charges,48.48% of total billed charges,66.11,116.15,,,fee schedule,116.51% of cms physician fee schedule,61.21,48.48,,48.968,percent of total billed charges,48.48% of total billed charges,88.38,70,,70.704,percent of total billed charges,70% of total billed charges,88.38,70,,70.704,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,61.21,48.48,,48.968,percent of total billed charges,48.48% of total billed charges,113.63,90,,90.904,percent of total billed charges,90% of total billed charges,48.48,113.63,
CLOSED TREATMENT FINGER FX,36010059,CDM,450,RC,26725,HCPCS,outpatient,,,425,255.00,,535,100,,,fee schedule,100% of asc tier groupings rate,204,48,,163.2,percent of total billed charges,48% of total billed charges,279.73,100,,,fee schedule,100% of bcbs custom fee schedule,279.73,100,,,fee schedule,100% of bcbs custom fee schedule,310.5,111,,,fee schedule,111% of bcbs custom fee schedule,212.5,50,,170,percent of total billed charges,50% of total billed charges,297.5,70,,238,percent of total billed charges,70% of total billed charges,206.04,48.48,,164.832,percent of total billed charges,48.48% of total billed charges,346.6,116.15,,,fee schedule,116.51% of cms physician fee schedule,206.04,48.48,,164.832,percent of total billed charges,48.48% of total billed charges,297.5,70,,238,percent of total billed charges,70% of total billed charges,297.5,70,,238,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,206.04,48.48,,164.832,percent of total billed charges,48.48% of total billed charges,382.5,90,,306,percent of total billed charges,90% of total billed charges,48.48,382.5,
BLADDER SCAN/POST VOID RESIDUAL,32002160,CDM,761,RC,51798,HCPCS,outpatient,,,179.98,107.99,,107.99,60,,86.392,percent of total billed charges,60% of total billed charges,86.39,48,,69.112,percent of total billed charges,48% of total billed charges,99.81,100,,,fee schedule,100% of bcbs custom fee schedule,99.81,100,,,fee schedule,100% of bcbs custom fee schedule,110.79,111,,,fee schedule,111% of bcbs custom fee schedule,89.99,50,,71.992,percent of total billed charges,50% of total billed charges,125.99,70,,100.792,percent of total billed charges,70% of total billed charges,87.25,48.48,,69.8,percent of total billed charges,48.48% of total billed charges,11.62,116.15,,,fee schedule,116.51% of cms physician fee schedule,87.25,48.48,,69.8,percent of total billed charges,48.48% of total billed charges,125.99,70,,100.792,percent of total billed charges,70% of total billed charges,125.99,70,,100.792,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,87.25,48.48,,69.8,percent of total billed charges,48.48% of total billed charges,161.98,90,,129.584,percent of total billed charges,90% of total billed charges,48.48,161.98,
DEBRD WD SURFACE >20CM,36000015,CDM,761,RC,97597,HCPCS,outpatient,,,676.65,405.99,,399,100,,,fee schedule,100% of asc tier groupings rate,324.79,48,,259.832,percent of total billed charges,48% of total billed charges,111.01,100,,,fee schedule,100% of bcbs custom fee schedule,111.01,100,,,fee schedule,100% of bcbs custom fee schedule,123.22,111,,,fee schedule,111% of bcbs custom fee schedule,338.33,50,,270.664,percent of total billed charges,50% of total billed charges,473.66,70,,378.928,percent of total billed charges,70% of total billed charges,328.04,48.48,,262.432,percent of total billed charges,48.48% of total billed charges,39.87,116.15,,,fee schedule,116.51% of cms physician fee schedule,328.04,48.48,,262.432,percent of total billed charges,48.48% of total billed charges,473.66,70,,378.928,percent of total billed charges,70% of total billed charges,473.66,70,,378.928,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,328.04,48.48,,262.432,percent of total billed charges,48.48% of total billed charges,608.99,90,,487.192,percent of total billed charges,90% of total billed charges,48.48,608.99,
DEBRD WD SURFACE <20SQCM,43601432,CDM,761,RC,97598,HCPCS,outpatient,,,676.65,405.99,,399,100,,,fee schedule,100% of asc tier groupings rate,324.79,48,,259.832,percent of total billed charges,48% of total billed charges,138.83,100,,,fee schedule,100% of bcbs custom fee schedule,138.83,100,,,fee schedule,100% of bcbs custom fee schedule,154.1,111,,,fee schedule,111% of bcbs custom fee schedule,338.33,50,,270.664,percent of total billed charges,50% of total billed charges,473.66,70,,378.928,percent of total billed charges,70% of total billed charges,328.04,48.48,,262.432,percent of total billed charges,48.48% of total billed charges,27.74,116.15,,,fee schedule,116.51% of cms physician fee schedule,328.04,48.48,,262.432,percent of total billed charges,48.48% of total billed charges,473.66,70,,378.928,percent of total billed charges,70% of total billed charges,473.66,70,,378.928,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,328.04,48.48,,262.432,percent of total billed charges,48.48% of total billed charges,608.99,90,,487.192,percent of total billed charges,90% of total billed charges,48.48,608.99,
DEBRIDE INFECTED SKIN ADD ON,,,981,RC,11001,HCPCS,outpatient,,,216.48,129.89,,,,,,other,not separately reimbusable,14.33,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,17.09,100,,,fee schedule,100% of cigna custom fee schedule,15.76,110,,,fee schedule,110% of cms physician fee schedule,14.47,101,,,fee schedule,101% of cms physician fee schedule ,14.47,116.15,,,fee schedule,116.51% of cms physician fee schedule,14.47,101,,,fee schedule,101% of cms physician fee schedule,27.23,110,,,fee schedule,110% of humana physician fee schedule,15.76,110,,,fee schedule,110% of humana physician fee schedule,21.5,150,,,fee schedule,100% of cms fee schedule,14.33,100,,,fee schedule,100% of cms physician fee schedule,21.5,150,,,fee schedule,150% of cms physician fee schedule,14.33,150,
INSERT TEMP BLADDER CATH,36011020,CDM,761,RC,51702,HCPCS,outpatient,,,218.75,131.25,,399,100,,,fee schedule,100% of asc tier groupings rate,105,48,,84,percent of total billed charges,48% of total billed charges,99.81,100,,,fee schedule,100% of bcbs custom fee schedule,99.81,100,,,fee schedule,100% of bcbs custom fee schedule,110.79,111,,,fee schedule,111% of bcbs custom fee schedule,109.38,50,,87.504,percent of total billed charges,50% of total billed charges,153.13,70,,122.504,percent of total billed charges,70% of total billed charges,106.05,48.48,,84.84,percent of total billed charges,48.48% of total billed charges,28.41,116.15,,,fee schedule,116.51% of cms physician fee schedule,106.05,48.48,,84.84,percent of total billed charges,48.48% of total billed charges,153.13,70,,122.504,percent of total billed charges,70% of total billed charges,153.13,70,,122.504,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,106.05,48.48,,84.84,percent of total billed charges,48.48% of total billed charges,196.88,90,,157.504,percent of total billed charges,90% of total billed charges,48.48,196.88,
PUNCTURE DRNGE OF ABSCESS,36010150,CDM,761,RC,10160,HCPCS,outpatient,,,220,132.00,,399,100,,,fee schedule,100% of asc tier groupings rate,105.6,48,,84.48,percent of total billed charges,48% of total billed charges,110,50,,88,percent of total billed charges,50% of total billed charges,110,50,,88,percent of total billed charges,50% of total billed charges,110,50,,88,percent of total billed charges,50% of total billed charges,110,50,,88,percent of total billed charges,50% of total billed charges,154,70,,123.2,percent of total billed charges,70% of total billed charges,106.66,48.48,,85.328,percent of total billed charges,48.48% of total billed charges,106.21,116.15,,,fee schedule,116.51% of cms physician fee schedule,106.66,48.48,,85.328,percent of total billed charges,48.48% of total billed charges,154,70,,123.2,percent of total billed charges,70% of total billed charges,154,70,,123.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,106.66,48.48,,85.328,percent of total billed charges,48.48% of total billed charges,198,90,,158.4,percent of total billed charges,90% of total billed charges,48.48,198,
BX EXTERNAL EAR,,,761,RC,69100,HCPCS,outpatient,,,402.5,241.50,,241.5,60,,193.2,percent of total billed charges,60% of total billed charges,193.2,48,,154.56,percent of total billed charges,48% of total billed charges,674.63,100,,,fee schedule,100% of bcbs custom fee schedule,674.63,100,,,fee schedule,100% of bcbs custom fee schedule,748.84,111,,,fee schedule,111% of bcbs custom fee schedule,201.25,50,,161,percent of total billed charges,50% of total billed charges,281.75,70,,225.4,percent of total billed charges,70% of total billed charges,195.13,48.48,,156.104,percent of total billed charges,48.48% of total billed charges,51.55,116.15,,,fee schedule,116.51% of cms physician fee schedule,195.13,48.48,,156.104,percent of total billed charges,48.48% of total billed charges,281.75,70,,225.4,percent of total billed charges,70% of total billed charges,281.75,70,,225.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,195.13,48.48,,156.104,percent of total billed charges,48.48% of total billed charges,362.25,90,,289.8,percent of total billed charges,90% of total billed charges,48.48,362.25,
DRAIN BLOOD HEMATOMA,36010010,CDM,761,RC,11740,HCPCS,outpatient,,,62.5,37.50,,399,100,,,fee schedule,100% of asc tier groupings rate,30,48,,24,percent of total billed charges,48% of total billed charges,122.18,100,,,fee schedule,100% of bcbs custom fee schedule,122.18,100,,,fee schedule,100% of bcbs custom fee schedule,135.62,111,,,fee schedule,111% of bcbs custom fee schedule,31.25,50,,25,percent of total billed charges,50% of total billed charges,43.75,70,,35,percent of total billed charges,70% of total billed charges,30.3,48.48,,24.24,percent of total billed charges,48.48% of total billed charges,34.93,116.15,,,fee schedule,116.51% of cms physician fee schedule,30.3,48.48,,24.24,percent of total billed charges,48.48% of total billed charges,43.75,70,,35,percent of total billed charges,70% of total billed charges,43.75,70,,35,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,30.3,48.48,,24.24,percent of total billed charges,48.48% of total billed charges,56.25,90,,45,percent of total billed charges,90% of total billed charges,30.3,90,
RPR S/N/AX/GEN/TRNK 2.5/>,36010012,CDM,761,RC,12001,HCPCS,outpatient,,,151.25,90.75,,399,100,,,fee schedule,100% of asc tier groupings rate,72.6,48,,58.08,percent of total billed charges,48% of total billed charges,322.02,100,,,fee schedule,100% of bcbs custom fee schedule,322.02,100,,,fee schedule,100% of bcbs custom fee schedule,357.44,111,,,fee schedule,111% of bcbs custom fee schedule,75.63,50,,60.504,percent of total billed charges,50% of total billed charges,105.88,70,,84.704,percent of total billed charges,70% of total billed charges,73.33,48.48,,58.664,percent of total billed charges,48.48% of total billed charges,51.06,116.15,,,fee schedule,116.51% of cms physician fee schedule,73.33,48.48,,58.664,percent of total billed charges,48.48% of total billed charges,105.88,70,,84.704,percent of total billed charges,70% of total billed charges,105.88,70,,84.704,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,73.33,48.48,,58.664,percent of total billed charges,48.48% of total billed charges,136.13,90,,108.904,percent of total billed charges,90% of total billed charges,48.48,136.13,
SHAVE BX SINGLE LESION,43601381,CDM,761,RC,11102,HCPCS,outpatient,,,142.56,85.54,,399,100,,,fee schedule,100% of asc tier groupings rate,68.43,48,,54.744,percent of total billed charges,48% of total billed charges,482.21,100,,,fee schedule,100% of bcbs custom fee schedule,482.21,100,,,fee schedule,100% of bcbs custom fee schedule,535.25,111,,,fee schedule,111% of bcbs custom fee schedule,71.28,50,,57.024,percent of total billed charges,50% of total billed charges,99.79,70,,79.832,percent of total billed charges,70% of total billed charges,69.11,48.48,,55.288,percent of total billed charges,48.48% of total billed charges,41.81,116.15,,,fee schedule,116.51% of cms physician fee schedule,69.11,48.48,,55.288,percent of total billed charges,48.48% of total billed charges,99.79,70,,79.832,percent of total billed charges,70% of total billed charges,99.79,70,,79.832,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,69.11,48.48,,55.288,percent of total billed charges,48.48% of total billed charges,128.3,90,,102.64,percent of total billed charges,90% of total billed charges,48.48,128.3,
TELEMEDICINE FACILITY FEE,,,780,RC,Q3014,HCPCS,outpatient,,,32.5,19.50,,19.5,60,,15.6,percent of total billed charges,60% of total billed charges,15.6,48,,12.48,percent of total billed charges,48% of total billed charges,16.25,50,,13,percent of total billed charges,50% of total billed charges,16.25,50,,13,percent of total billed charges,50% of total billed charges,16.25,50,,13,percent of total billed charges,50% of total billed charges,16.25,50,,13,percent of total billed charges,50% of total billed charges,22.75,70,,18.2,percent of total billed charges,70% of total billed charges,15.76,48.48,,12.608,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,15.76,48.48,,12.608,percent of total billed charges,48.48% of total billed charges,22.75,70,,18.2,percent of total billed charges,70% of total billed charges,22.75,70,,18.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,15.76,48.48,,12.608,percent of total billed charges,48.48% of total billed charges,29.25,90,,23.4,percent of total billed charges,90% of total billed charges,15.76,90,
FINE NEEDLE ASPIRATION OUTPT,36011040,CDM,761,RC,10021,HCPCS,outpatient,,,212.24,127.34,,399,100,,,fee schedule,100% of asc tier groupings rate,101.88,48,,81.504,percent of total billed charges,48% of total billed charges,799.69,100,,,fee schedule,100% of bcbs custom fee schedule,799.69,100,,,fee schedule,100% of bcbs custom fee schedule,887.66,111,,,fee schedule,111% of bcbs custom fee schedule,106.12,50,,84.896,percent of total billed charges,50% of total billed charges,148.57,70,,118.856,percent of total billed charges,70% of total billed charges,102.89,48.48,,82.312,percent of total billed charges,48.48% of total billed charges,61.59,116.15,,,fee schedule,116.51% of cms physician fee schedule,102.89,48.48,,82.312,percent of total billed charges,48.48% of total billed charges,148.57,70,,118.856,percent of total billed charges,70% of total billed charges,148.57,70,,118.856,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,102.89,48.48,,82.312,percent of total billed charges,48.48% of total billed charges,191.02,90,,152.816,percent of total billed charges,90% of total billed charges,48.48,191.02,
OBSERVATION PER HOUR,32009036,CDM,762,RC,G0378,HCPCS,outpatient,,,112.5,67.50,,67.5,60,,54,percent of total billed charges,60% of total billed charges,54,48,,43.2,percent of total billed charges,48% of total billed charges,31.17,100,,,fee schedule,100% of bcbs custom fee schedule,31.17,100,,,fee schedule,100% of bcbs custom fee schedule,34.6,111,,,fee schedule,111% of bcbs custom fee schedule,950,100,,,case rate,pays based on per visit rate,78.75,70,,63,percent of total billed charges,70% of total billed charges,54.54,48.48,,43.632,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,54.54,48.48,,43.632,percent of total billed charges,48.48% of total billed charges,78.75,70,,63,percent of total billed charges,70% of total billed charges,78.75,70,,63,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,54.54,48.48,,43.632,percent of total billed charges,48.48% of total billed charges,101.25,90,,81,percent of total billed charges,90% of total billed charges,48.48,101.25,
INSERT TEMP BLADDER CATH,36011020,CDM,762,RC,51702,HCPCS,outpatient,,,218.75,131.25,,399,100,,,fee schedule,100% of asc tier groupings rate,105,48,,84,percent of total billed charges,48% of total billed charges,99.81,100,,,fee schedule,100% of bcbs custom fee schedule,99.81,100,,,fee schedule,100% of bcbs custom fee schedule,110.79,111,,,fee schedule,111% of bcbs custom fee schedule,950,100,,,case rate,pays based on per visit rate,153.13,70,,122.504,percent of total billed charges,70% of total billed charges,106.05,48.48,,84.84,percent of total billed charges,48.48% of total billed charges,28.41,116.15,,,fee schedule,116.51% of cms physician fee schedule,106.05,48.48,,84.84,percent of total billed charges,48.48% of total billed charges,153.13,70,,122.504,percent of total billed charges,70% of total billed charges,153.13,70,,122.504,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,106.05,48.48,,84.84,percent of total billed charges,48.48% of total billed charges,196.88,90,,157.504,percent of total billed charges,90% of total billed charges,48.48,196.88,
OBS DIRECT ADMIT 1ST HR,,,762,RC,G0379,HCPCS,outpatient,,,317.5,190.50,,190.5,60,,152.4,percent of total billed charges,60% of total billed charges,152.4,48,,121.92,percent of total billed charges,48% of total billed charges,851.37,100,,,fee schedule,100% of bcbs custom fee schedule,851.37,100,,,fee schedule,100% of bcbs custom fee schedule,945.02,111,,,fee schedule,111% of bcbs custom fee schedule,950,100,,,case rate,pays based on per visit rate,222.25,70,,177.8,percent of total billed charges,70% of total billed charges,153.92,48.48,,123.136,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,153.92,48.48,,123.136,percent of total billed charges,48.48% of total billed charges,222.25,70,,177.8,percent of total billed charges,70% of total billed charges,222.25,70,,177.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,153.92,48.48,,123.136,percent of total billed charges,48.48% of total billed charges,285.75,90,,228.6,percent of total billed charges,90% of total billed charges,48.48,285.75,
OBS ADMIT/DIS SAME DAY,43710018,CDM,762,RC,99234,HCPCS,outpatient,,,191.25,114.75,,114.75,60,,91.8,percent of total billed charges,60% of total billed charges,91.8,48,,73.44,percent of total billed charges,48% of total billed charges,95.63,50,,76.504,percent of total billed charges,50% of total billed charges,95.63,50,,76.504,percent of total billed charges,50% of total billed charges,95.63,50,,76.504,percent of total billed charges,50% of total billed charges,950,100,,,case rate,pays based on per visit rate,133.88,70,,107.104,percent of total billed charges,70% of total billed charges,92.72,48.48,,74.176,percent of total billed charges,48.48% of total billed charges,109.56,116.15,,,fee schedule,116.51% of cms physician fee schedule,92.72,48.48,,74.176,percent of total billed charges,48.48% of total billed charges,133.88,70,,107.104,percent of total billed charges,70% of total billed charges,133.88,70,,107.104,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,92.72,48.48,,74.176,percent of total billed charges,48.48% of total billed charges,172.13,90,,137.704,percent of total billed charges,90% of total billed charges,48.48,172.13,
OBS ADMIT/DIS SAME DY MOD,43710019,CDM,982,RC,99235,HCPCS,outpatient,,,300,180.00,,,,,,other,not separately reimbusable,153.44,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,164.54,100,,,fee schedule,100% of cigna custom fee schedule,168.78,110,,,fee schedule,110% of cms physician fee schedule,154.97,101,,,fee schedule,101% of cms physician fee schedule ,154.97,116.15,,,fee schedule,116.51% of cms physician fee schedule,154.97,101,,,fee schedule,101% of cms physician fee schedule,291.54,110,,,fee schedule,110% of humana physician fee schedule,168.78,110,,,fee schedule,110% of humana physician fee schedule,230.16,150,,,fee schedule,100% of cms fee schedule,153.44,100,,,fee schedule,100% of cms physician fee schedule,230.16,150,,,fee schedule,150% of cms physician fee schedule,100,230.16,
NG TUBE PLACEMENT,,,762,RC,43752,HCPCS,outpatient,,,250,150.00,,535,100,,,fee schedule,100% of asc tier groupings rate,120,48,,96,percent of total billed charges,48% of total billed charges,216.16,100,,,fee schedule,100% of bcbs custom fee schedule,216.16,100,,,fee schedule,100% of bcbs custom fee schedule,239.94,111,,,fee schedule,111% of bcbs custom fee schedule,950,100,,,case rate,pays based on per visit rate,175,70,,140,percent of total billed charges,70% of total billed charges,121.2,48.48,,96.96,percent of total billed charges,48.48% of total billed charges,44.88,116.15,,,fee schedule,116.51% of cms physician fee schedule,121.2,48.48,,96.96,percent of total billed charges,48.48% of total billed charges,175,70,,140,percent of total billed charges,70% of total billed charges,175,70,,140,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,121.2,48.48,,96.96,percent of total billed charges,48.48% of total billed charges,225,90,,180,percent of total billed charges,90% of total billed charges,48.48,225,
REVL DEVIT SKIN <20SQCM,36000015,CDM,450,RC,97597,HCPCS,outpatient,,,676.65,405.99,,399,100,,,fee schedule,100% of asc tier groupings rate,324.79,48,,259.832,percent of total billed charges,48% of total billed charges,111.01,100,,,fee schedule,100% of bcbs custom fee schedule,111.01,100,,,fee schedule,100% of bcbs custom fee schedule,123.22,111,,,fee schedule,111% of bcbs custom fee schedule,338.33,50,,270.664,percent of total billed charges,50% of total billed charges,473.66,70,,378.928,percent of total billed charges,70% of total billed charges,328.04,48.48,,262.432,percent of total billed charges,48.48% of total billed charges,39.87,116.15,,,fee schedule,116.51% of cms physician fee schedule,328.04,48.48,,262.432,percent of total billed charges,48.48% of total billed charges,473.66,70,,378.928,percent of total billed charges,70% of total billed charges,473.66,70,,378.928,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,328.04,48.48,,262.432,percent of total billed charges,48.48% of total billed charges,608.99,90,,487.192,percent of total billed charges,90% of total billed charges,48.48,608.99,
TREAT ANKLE DISLOCATION,36011033,CDM,450,RC,27840,HCPCS,outpatient,,,686.25,411.75,,399,100,,,fee schedule,100% of asc tier groupings rate,329.4,48,,263.52,percent of total billed charges,48% of total billed charges,279.73,100,,,fee schedule,100% of bcbs custom fee schedule,279.73,100,,,fee schedule,100% of bcbs custom fee schedule,310.5,111,,,fee schedule,111% of bcbs custom fee schedule,343.13,50,,274.504,percent of total billed charges,50% of total billed charges,480.38,70,,384.304,percent of total billed charges,70% of total billed charges,332.69,48.48,,266.152,percent of total billed charges,48.48% of total billed charges,439.35,116.15,,,fee schedule,116.51% of cms physician fee schedule,332.69,48.48,,266.152,percent of total billed charges,48.48% of total billed charges,480.38,70,,384.304,percent of total billed charges,70% of total billed charges,480.38,70,,384.304,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,332.69,48.48,,266.152,percent of total billed charges,48.48% of total billed charges,617.63,90,,494.104,percent of total billed charges,90% of total billed charges,48.48,617.63,
Treat Knuckle Dislocation,36010057,CDM,450,RC,26700,HCPCS,outpatient,,,604.5,362.70,,362.7,60,,290.16,percent of total billed charges,60% of total billed charges,290.16,48,,232.128,percent of total billed charges,48% of total billed charges,279.73,100,,,fee schedule,100% of bcbs custom fee schedule,279.73,100,,,fee schedule,100% of bcbs custom fee schedule,310.5,111,,,fee schedule,111% of bcbs custom fee schedule,302.25,50,,241.8,percent of total billed charges,50% of total billed charges,423.15,70,,338.52,percent of total billed charges,70% of total billed charges,293.06,48.48,,234.448,percent of total billed charges,48.48% of total billed charges,358.15,116.15,,,fee schedule,116.51% of cms physician fee schedule,293.06,48.48,,234.448,percent of total billed charges,48.48% of total billed charges,423.15,70,,338.52,percent of total billed charges,70% of total billed charges,423.15,70,,338.52,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,293.06,48.48,,234.448,percent of total billed charges,48.48% of total billed charges,544.05,90,,435.24,percent of total billed charges,90% of total billed charges,48.48,544.05,
IV INFUS THER UP TO 1HR,32000013,CDM,260,RC,96365,HCPCS,outpatient,,,208.75,125.25,,125.25,60,,100.2,percent of total billed charges,60% of total billed charges,100.2,48,,80.16,percent of total billed charges,48% of total billed charges,105.22,100,,,fee schedule,100% of bcbs custom fee schedule,105.22,100,,,fee schedule,100% of bcbs custom fee schedule,116.79,111,,,fee schedule,111% of bcbs custom fee schedule,104.38,50,,83.504,percent of total billed charges,50% of total billed charges,146.13,70,,116.904,percent of total billed charges,70% of total billed charges,101.2,48.48,,80.96,percent of total billed charges,48.48% of total billed charges,65.09,116.15,,,fee schedule,116.51% of cms physician fee schedule,101.2,48.48,,80.96,percent of total billed charges,48.48% of total billed charges,146.13,70,,116.904,percent of total billed charges,70% of total billed charges,146.13,70,,116.904,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,101.2,48.48,,80.96,percent of total billed charges,48.48% of total billed charges,187.88,90,,150.304,percent of total billed charges,90% of total billed charges,48.48,187.88,
ER LEVEL I,36000041,CDM,450,RC,99281,HCPCS,outpatient,,,127.5,76.50,,63.75,60,,51,percent of total billed charges,60% of total billed charges,61.2,48,,48.96,percent of total billed charges,48% of total billed charges,162.35,100,,,fee schedule,100% of bcbs custom fee schedule,162.35,100,,,fee schedule,100% of bcbs custom fee schedule,180.21,111,,,fee schedule,111% of bcbs custom fee schedule,450,100,,,case rate,pays based on per visit rate,89.25,70,,71.4,percent of total billed charges,70% of total billed charges,61.81,48.48,,49.448,percent of total billed charges,48.48% of total billed charges,13.02,116.15,,,fee schedule,116.51% of cms physician fee schedule,61.81,48.48,,49.448,percent of total billed charges,48.48% of total billed charges,89.25,70,,71.4,percent of total billed charges,70% of total billed charges,89.25,70,,71.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,61.81,48.48,,49.448,percent of total billed charges,48.48% of total billed charges,114.75,90,,91.8,percent of total billed charges,90% of total billed charges,48.48,114.75,
ER LEVEL II,36009002,CDM,450,RC,99282,HCPCS,outpatient,,,137.5,82.50,,68.75,60,,55,percent of total billed charges,60% of total billed charges,66,48,,52.8,percent of total billed charges,48% of total billed charges,162.35,100,,,fee schedule,100% of bcbs custom fee schedule,162.35,100,,,fee schedule,100% of bcbs custom fee schedule,180.21,111,,,fee schedule,111% of bcbs custom fee schedule,450,100,,,case rate,pays based on per visit rate,96.25,70,,77,percent of total billed charges,70% of total billed charges,66.66,48.48,,53.328,percent of total billed charges,48.48% of total billed charges,47.48,116.15,,,fee schedule,116.51% of cms physician fee schedule,66.66,48.48,,53.328,percent of total billed charges,48.48% of total billed charges,96.25,70,,77,percent of total billed charges,70% of total billed charges,96.25,70,,77,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,66.66,48.48,,53.328,percent of total billed charges,48.48% of total billed charges,123.75,90,,99,percent of total billed charges,90% of total billed charges,48.48,123.75,
ER LEVEL III,36009003,CDM,450,RC,99283,HCPCS,outpatient,,,228.75,137.25,,114.38,60,,91.504,percent of total billed charges,60% of total billed charges,109.8,48,,87.84,percent of total billed charges,48% of total billed charges,284.22,100,,,fee schedule,100% of bcbs custom fee schedule,284.22,100,,,fee schedule,100% of bcbs custom fee schedule,315.48,111,,,fee schedule,111% of bcbs custom fee schedule,450,100,,,case rate,pays based on per visit rate,160.13,70,,128.104,percent of total billed charges,70% of total billed charges,110.9,48.48,,88.72,percent of total billed charges,48.48% of total billed charges,80.89,116.15,,,fee schedule,116.51% of cms physician fee schedule,110.9,48.48,,88.72,percent of total billed charges,48.48% of total billed charges,160.13,70,,128.104,percent of total billed charges,70% of total billed charges,160.13,70,,128.104,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,110.9,48.48,,88.72,percent of total billed charges,48.48% of total billed charges,205.88,90,,164.704,percent of total billed charges,90% of total billed charges,48.48,205.88,
ER LEVEL IV,36009004,CDM,450,RC,99284,HCPCS,outpatient,,,318.75,191.25,,159.38,60,,127.504,percent of total billed charges,60% of total billed charges,153,48,,122.4,percent of total billed charges,48% of total billed charges,494.56,100,,,fee schedule,100% of bcbs custom fee schedule,494.56,100,,,fee schedule,100% of bcbs custom fee schedule,548.96,111,,,fee schedule,111% of bcbs custom fee schedule,450,100,,,case rate,pays based on per visit rate,223.13,70,,178.504,percent of total billed charges,70% of total billed charges,154.53,48.48,,123.624,percent of total billed charges,48.48% of total billed charges,137.73,116.15,,,fee schedule,116.51% of cms physician fee schedule,154.53,48.48,,123.624,percent of total billed charges,48.48% of total billed charges,223.13,70,,178.504,percent of total billed charges,70% of total billed charges,223.13,70,,178.504,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,154.53,48.48,,123.624,percent of total billed charges,48.48% of total billed charges,286.88,90,,229.504,percent of total billed charges,90% of total billed charges,48.48,286.88,
ER LEVEL V,36009005,CDM,450,RC,99285,HCPCS,outpatient,,,603.75,362.25,,301.88,60,,241.504,percent of total billed charges,60% of total billed charges,289.8,48,,231.84,percent of total billed charges,48% of total billed charges,494.56,100,,,fee schedule,100% of bcbs custom fee schedule,494.56,100,,,fee schedule,100% of bcbs custom fee schedule,548.96,111,,,fee schedule,111% of bcbs custom fee schedule,450,100,,,case rate,pays based on per visit rate,422.63,70,,338.104,percent of total billed charges,70% of total billed charges,292.7,48.48,,234.16,percent of total billed charges,48.48% of total billed charges,199.64,116.15,,,fee schedule,116.51% of cms physician fee schedule,292.7,48.48,,234.16,percent of total billed charges,48.48% of total billed charges,422.63,70,,338.104,percent of total billed charges,70% of total billed charges,422.63,70,,338.104,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,292.7,48.48,,234.16,percent of total billed charges,48.48% of total billed charges,543.38,90,,434.704,percent of total billed charges,90% of total billed charges,48.48,543.38,
EVAC SUBUNGL HEMATOMA,36010010,CDM,450,RC,11740,HCPCS,outpatient,,,50,30.00,,399,100,,,fee schedule,100% of asc tier groupings rate,24,48,,19.2,percent of total billed charges,48% of total billed charges,122.18,100,,,fee schedule,100% of bcbs custom fee schedule,122.18,100,,,fee schedule,100% of bcbs custom fee schedule,135.62,111,,,fee schedule,111% of bcbs custom fee schedule,25,50,,20,percent of total billed charges,50% of total billed charges,35,70,,28,percent of total billed charges,70% of total billed charges,24.24,48.48,,19.392,percent of total billed charges,48.48% of total billed charges,34.93,116.15,,,fee schedule,116.51% of cms physician fee schedule,24.24,48.48,,19.392,percent of total billed charges,48.48% of total billed charges,35,70,,28,percent of total billed charges,70% of total billed charges,35,70,,28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,24.24,48.48,,19.392,percent of total billed charges,48.48% of total billed charges,45,90,,36,percent of total billed charges,90% of total billed charges,24.24,90,
SMP REP S/N/A/G/TR/E;2.5<,36010012,CDM,450,RC,12001,HCPCS,outpatient,,,151.25,90.75,,399,100,,,fee schedule,100% of asc tier groupings rate,72.6,48,,58.08,percent of total billed charges,48% of total billed charges,322.02,100,,,fee schedule,100% of bcbs custom fee schedule,322.02,100,,,fee schedule,100% of bcbs custom fee schedule,357.44,111,,,fee schedule,111% of bcbs custom fee schedule,75.63,50,,60.504,percent of total billed charges,50% of total billed charges,105.88,70,,84.704,percent of total billed charges,70% of total billed charges,73.33,48.48,,58.664,percent of total billed charges,48.48% of total billed charges,51.06,116.15,,,fee schedule,116.51% of cms physician fee schedule,73.33,48.48,,58.664,percent of total billed charges,48.48% of total billed charges,105.88,70,,84.704,percent of total billed charges,70% of total billed charges,105.88,70,,84.704,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,73.33,48.48,,58.664,percent of total billed charges,48.48% of total billed charges,136.13,90,,108.904,percent of total billed charges,90% of total billed charges,48.48,136.13,
SMP RE S/N/A/G/T/E2.6-7.5,36010013,CDM,450,RC,12002,HCPCS,outpatient,,,151.25,90.75,,90.75,60,,72.6,percent of total billed charges,60% of total billed charges,72.6,48,,58.08,percent of total billed charges,48% of total billed charges,322.02,100,,,fee schedule,100% of bcbs custom fee schedule,322.02,100,,,fee schedule,100% of bcbs custom fee schedule,357.44,111,,,fee schedule,111% of bcbs custom fee schedule,75.63,50,,60.504,percent of total billed charges,50% of total billed charges,105.88,70,,84.704,percent of total billed charges,70% of total billed charges,73.33,48.48,,58.664,percent of total billed charges,48.48% of total billed charges,67.34,116.15,,,fee schedule,116.51% of cms physician fee schedule,73.33,48.48,,58.664,percent of total billed charges,48.48% of total billed charges,105.88,70,,84.704,percent of total billed charges,70% of total billed charges,105.88,70,,84.704,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,73.33,48.48,,58.664,percent of total billed charges,48.48% of total billed charges,136.13,90,,108.904,percent of total billed charges,90% of total billed charges,48.48,136.13,
SMPRE S/N/A/G/T/E7.6-12.5,36010014,CDM,450,RC,12004,HCPCS,outpatient,,,150,90.00,,399,100,,,fee schedule,100% of asc tier groupings rate,72,48,,57.6,percent of total billed charges,48% of total billed charges,322.02,100,,,fee schedule,100% of bcbs custom fee schedule,322.02,100,,,fee schedule,100% of bcbs custom fee schedule,357.44,111,,,fee schedule,111% of bcbs custom fee schedule,75,50,,60,percent of total billed charges,50% of total billed charges,105,70,,84,percent of total billed charges,70% of total billed charges,72.72,48.48,,58.176,percent of total billed charges,48.48% of total billed charges,84.42,116.15,,,fee schedule,116.51% of cms physician fee schedule,72.72,48.48,,58.176,percent of total billed charges,48.48% of total billed charges,105,70,,84,percent of total billed charges,70% of total billed charges,105,70,,84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,72.72,48.48,,58.176,percent of total billed charges,48.48% of total billed charges,135,90,,108,percent of total billed charges,90% of total billed charges,48.48,135,
SMPRE S/N/A/G/T/E12.6-20,36010015,CDM,450,RC,12005,HCPCS,outpatient,,,150,90.00,,535,100,,,fee schedule,100% of asc tier groupings rate,72,48,,57.6,percent of total billed charges,48% of total billed charges,75,50,,60,percent of total billed charges,50% of total billed charges,75,50,,60,percent of total billed charges,50% of total billed charges,75,50,,60,percent of total billed charges,50% of total billed charges,75,50,,60,percent of total billed charges,50% of total billed charges,105,70,,84,percent of total billed charges,70% of total billed charges,72.72,48.48,,58.176,percent of total billed charges,48.48% of total billed charges,109.44,116.15,,,fee schedule,116.51% of cms physician fee schedule,72.72,48.48,,58.176,percent of total billed charges,48.48% of total billed charges,105,70,,84,percent of total billed charges,70% of total billed charges,105,70,,84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,72.72,48.48,,58.176,percent of total billed charges,48.48% of total billed charges,135,90,,108,percent of total billed charges,90% of total billed charges,48.48,135,
SMP REP F/E/N/L/MM;2.5CM<,36010016,CDM,450,RC,12011,HCPCS,outpatient,,,150,90.00,,90,60,,72,percent of total billed charges,60% of total billed charges,72,48,,57.6,percent of total billed charges,48% of total billed charges,322.02,100,,,fee schedule,100% of bcbs custom fee schedule,322.02,100,,,fee schedule,100% of bcbs custom fee schedule,357.44,111,,,fee schedule,111% of bcbs custom fee schedule,75,50,,60,percent of total billed charges,50% of total billed charges,105,70,,84,percent of total billed charges,70% of total billed charges,72.72,48.48,,58.176,percent of total billed charges,48.48% of total billed charges,63.52,116.15,,,fee schedule,116.51% of cms physician fee schedule,72.72,48.48,,58.176,percent of total billed charges,48.48% of total billed charges,105,70,,84,percent of total billed charges,70% of total billed charges,105,70,,84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,72.72,48.48,,58.176,percent of total billed charges,48.48% of total billed charges,135,90,,108,percent of total billed charges,90% of total billed charges,48.48,135,
SMP REP F/E/N/L/MM;2.6-5,36010017,CDM,450,RC,12013,HCPCS,outpatient,,,150,90.00,,90,60,,72,percent of total billed charges,60% of total billed charges,72,48,,57.6,percent of total billed charges,48% of total billed charges,322.02,100,,,fee schedule,100% of bcbs custom fee schedule,322.02,100,,,fee schedule,100% of bcbs custom fee schedule,357.44,111,,,fee schedule,111% of bcbs custom fee schedule,75,50,,60,percent of total billed charges,50% of total billed charges,105,70,,84,percent of total billed charges,70% of total billed charges,72.72,48.48,,58.176,percent of total billed charges,48.48% of total billed charges,66.93,116.15,,,fee schedule,116.51% of cms physician fee schedule,72.72,48.48,,58.176,percent of total billed charges,48.48% of total billed charges,105,70,,84,percent of total billed charges,70% of total billed charges,105,70,,84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,72.72,48.48,,58.176,percent of total billed charges,48.48% of total billed charges,135,90,,108,percent of total billed charges,90% of total billed charges,48.48,135,
SMPRE F/E/N/L/MM;5.1-7.5,36010151,CDM,450,RC,12014,HCPCS,outpatient,,,150,90.00,,399,100,,,fee schedule,100% of asc tier groupings rate,72,48,,57.6,percent of total billed charges,48% of total billed charges,75,50,,60,percent of total billed charges,50% of total billed charges,75,50,,60,percent of total billed charges,50% of total billed charges,75,50,,60,percent of total billed charges,50% of total billed charges,75,50,,60,percent of total billed charges,50% of total billed charges,105,70,,84,percent of total billed charges,70% of total billed charges,72.72,48.48,,58.176,percent of total billed charges,48.48% of total billed charges,86.71,116.15,,,fee schedule,116.51% of cms physician fee schedule,72.72,48.48,,58.176,percent of total billed charges,48.48% of total billed charges,105,70,,84,percent of total billed charges,70% of total billed charges,105,70,,84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,72.72,48.48,,58.176,percent of total billed charges,48.48% of total billed charges,135,90,,108,percent of total billed charges,90% of total billed charges,48.48,135,
INTMD WND RPR 12.6-20.0CM,36010139,CDM,450,RC,12035,HCPCS,outpatient,,,441.25,264.75,,535,100,,,fee schedule,100% of asc tier groupings rate,211.8,48,,169.44,percent of total billed charges,48% of total billed charges,220.63,50,,176.504,percent of total billed charges,50% of total billed charges,220.63,50,,176.504,percent of total billed charges,50% of total billed charges,220.63,50,,176.504,percent of total billed charges,50% of total billed charges,220.63,50,,176.504,percent of total billed charges,50% of total billed charges,308.88,70,,247.104,percent of total billed charges,70% of total billed charges,213.92,48.48,,171.136,percent of total billed charges,48.48% of total billed charges,268.52,116.15,,,fee schedule,116.51% of cms physician fee schedule,213.92,48.48,,171.136,percent of total billed charges,48.48% of total billed charges,308.88,70,,247.104,percent of total billed charges,70% of total billed charges,308.88,70,,247.104,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,213.92,48.48,,171.136,percent of total billed charges,48.48% of total billed charges,397.13,90,,317.704,percent of total billed charges,90% of total billed charges,48.48,397.13,
SMPRE F/E/N/L/MM;7.5-12.5,36010164,CDM,450,RC,12015,HCPCS,outpatient,,,150,90.00,,399,100,,,fee schedule,100% of asc tier groupings rate,72,48,,57.6,percent of total billed charges,48% of total billed charges,75,50,,60,percent of total billed charges,50% of total billed charges,75,50,,60,percent of total billed charges,50% of total billed charges,75,50,,60,percent of total billed charges,50% of total billed charges,75,50,,60,percent of total billed charges,50% of total billed charges,105,70,,84,percent of total billed charges,70% of total billed charges,72.72,48.48,,58.176,percent of total billed charges,48.48% of total billed charges,108.81,116.15,,,fee schedule,116.51% of cms physician fee schedule,72.72,48.48,,58.176,percent of total billed charges,48.48% of total billed charges,105,70,,84,percent of total billed charges,70% of total billed charges,105,70,,84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,72.72,48.48,,58.176,percent of total billed charges,48.48% of total billed charges,135,90,,108,percent of total billed charges,90% of total billed charges,48.48,135,
INTMD WND REP S/T/EXT2.5<,36010018,CDM,450,RC,12031,HCPCS,outpatient,,,441.25,264.75,,399,100,,,fee schedule,100% of asc tier groupings rate,211.8,48,,169.44,percent of total billed charges,48% of total billed charges,616.4,100,,,fee schedule,100% of bcbs custom fee schedule,616.4,100,,,fee schedule,100% of bcbs custom fee schedule,684.2,111,,,fee schedule,111% of bcbs custom fee schedule,220.63,50,,176.504,percent of total billed charges,50% of total billed charges,308.88,70,,247.104,percent of total billed charges,70% of total billed charges,213.92,48.48,,171.136,percent of total billed charges,48.48% of total billed charges,165.94,116.15,,,fee schedule,116.51% of cms physician fee schedule,213.92,48.48,,171.136,percent of total billed charges,48.48% of total billed charges,308.88,70,,247.104,percent of total billed charges,70% of total billed charges,308.88,70,,247.104,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,213.92,48.48,,171.136,percent of total billed charges,48.48% of total billed charges,397.13,90,,317.704,percent of total billed charges,90% of total billed charges,48.48,397.13,
INT WND RE S/A/T/E2.6-7.5,36010019,CDM,450,RC,12032,HCPCS,outpatient,,,441.25,264.75,,399,100,,,fee schedule,100% of asc tier groupings rate,211.8,48,,169.44,percent of total billed charges,48% of total billed charges,616.4,100,,,fee schedule,100% of bcbs custom fee schedule,616.4,100,,,fee schedule,100% of bcbs custom fee schedule,684.2,111,,,fee schedule,111% of bcbs custom fee schedule,220.63,50,,176.504,percent of total billed charges,50% of total billed charges,308.88,70,,247.104,percent of total billed charges,70% of total billed charges,213.92,48.48,,171.136,percent of total billed charges,48.48% of total billed charges,208.13,116.15,,,fee schedule,116.51% of cms physician fee schedule,213.92,48.48,,171.136,percent of total billed charges,48.48% of total billed charges,308.88,70,,247.104,percent of total billed charges,70% of total billed charges,308.88,70,,247.104,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,213.92,48.48,,171.136,percent of total billed charges,48.48% of total billed charges,397.13,90,,317.704,percent of total billed charges,90% of total billed charges,48.48,397.13,
INT WND REP N-HF/GEN 2.5<,36010021,CDM,450,RC,12041,HCPCS,outpatient,,,454,272.40,,399,100,,,fee schedule,100% of asc tier groupings rate,217.92,48,,174.336,percent of total billed charges,48% of total billed charges,322.02,100,,,fee schedule,100% of bcbs custom fee schedule,322.02,100,,,fee schedule,100% of bcbs custom fee schedule,357.44,111,,,fee schedule,111% of bcbs custom fee schedule,227,50,,181.6,percent of total billed charges,50% of total billed charges,317.8,70,,254.24,percent of total billed charges,70% of total billed charges,220.1,48.48,,176.08,percent of total billed charges,48.48% of total billed charges,160.09,116.15,,,fee schedule,116.51% of cms physician fee schedule,220.1,48.48,,176.08,percent of total billed charges,48.48% of total billed charges,317.8,70,,254.24,percent of total billed charges,70% of total billed charges,317.8,70,,254.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,220.1,48.48,,176.08,percent of total billed charges,48.48% of total billed charges,408.6,90,,326.88,percent of total billed charges,90% of total billed charges,48.48,408.6,
INT REP N-HF/GEN 2.6-7.5,36010022,CDM,450,RC,12042,HCPCS,outpatient,,,440,264.00,,399,100,,,fee schedule,100% of asc tier groupings rate,211.2,48,,168.96,percent of total billed charges,48% of total billed charges,616.4,100,,,fee schedule,100% of bcbs custom fee schedule,616.4,100,,,fee schedule,100% of bcbs custom fee schedule,684.2,111,,,fee schedule,111% of bcbs custom fee schedule,220,50,,176,percent of total billed charges,50% of total billed charges,308,70,,246.4,percent of total billed charges,70% of total billed charges,213.31,48.48,,170.648,percent of total billed charges,48.48% of total billed charges,215.26,116.15,,,fee schedule,116.51% of cms physician fee schedule,213.31,48.48,,170.648,percent of total billed charges,48.48% of total billed charges,308,70,,246.4,percent of total billed charges,70% of total billed charges,308,70,,246.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,213.31,48.48,,170.648,percent of total billed charges,48.48% of total billed charges,396,90,,316.8,percent of total billed charges,90% of total billed charges,48.48,396,
INTERMEDIATE REPAIR FACE/MM 2.5/<,36010023,CDM,450,RC,12051,HCPCS,outpatient,,,436.07,261.64,,399,100,,,fee schedule,100% of asc tier groupings rate,209.31,48,,167.448,percent of total billed charges,48% of total billed charges,616.4,100,,,fee schedule,100% of bcbs custom fee schedule,616.4,100,,,fee schedule,100% of bcbs custom fee schedule,684.2,111,,,fee schedule,111% of bcbs custom fee schedule,218.04,50,,174.432,percent of total billed charges,50% of total billed charges,305.25,70,,244.2,percent of total billed charges,70% of total billed charges,211.41,48.48,,169.128,percent of total billed charges,48.48% of total billed charges,186.43,116.15,,,fee schedule,116.51% of cms physician fee schedule,211.41,48.48,,169.128,percent of total billed charges,48.48% of total billed charges,305.25,70,,244.2,percent of total billed charges,70% of total billed charges,305.25,70,,244.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,211.41,48.48,,169.128,percent of total billed charges,48.48% of total billed charges,392.46,90,,313.968,percent of total billed charges,90% of total billed charges,48.48,392.46,
INTMD RPR FACE/MM 2.6-5.0 CM,36010024,CDM,450,RC,12052,HCPCS,outpatient,,,510,306.00,,399,100,,,fee schedule,100% of asc tier groupings rate,244.8,48,,195.84,percent of total billed charges,48% of total billed charges,616.4,100,,,fee schedule,100% of bcbs custom fee schedule,616.4,100,,,fee schedule,100% of bcbs custom fee schedule,684.2,111,,,fee schedule,111% of bcbs custom fee schedule,255,50,,204,percent of total billed charges,50% of total billed charges,357,70,,285.6,percent of total billed charges,70% of total billed charges,247.25,48.48,,197.8,percent of total billed charges,48.48% of total billed charges,219.58,116.15,,,fee schedule,116.51% of cms physician fee schedule,247.25,48.48,,197.8,percent of total billed charges,48.48% of total billed charges,357,70,,285.6,percent of total billed charges,70% of total billed charges,357,70,,285.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,247.25,48.48,,197.8,percent of total billed charges,48.48% of total billed charges,459,90,,367.2,percent of total billed charges,90% of total billed charges,48.48,459,
INT WND REP FCE-MM5.17.5,36010132,CDM,450,RC,12053,HCPCS,outpatient,,,284.31,170.59,,399,100,,,fee schedule,100% of asc tier groupings rate,136.47,48,,109.176,percent of total billed charges,48% of total billed charges,142.16,50,,113.728,percent of total billed charges,50% of total billed charges,142.16,50,,113.728,percent of total billed charges,50% of total billed charges,142.16,50,,113.728,percent of total billed charges,50% of total billed charges,142.16,50,,113.728,percent of total billed charges,50% of total billed charges,199.02,70,,159.216,percent of total billed charges,70% of total billed charges,137.83,48.48,,110.264,percent of total billed charges,48.48% of total billed charges,237.46,116.15,,,fee schedule,116.51% of cms physician fee schedule,137.83,48.48,,110.264,percent of total billed charges,48.48% of total billed charges,199.02,70,,159.216,percent of total billed charges,70% of total billed charges,199.02,70,,159.216,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,137.83,48.48,,110.264,percent of total billed charges,48.48% of total billed charges,255.88,90,,204.704,percent of total billed charges,90% of total billed charges,48.48,255.88,
CMPLX REP F/G/H/F;1.1-2.5,36010136,CDM,450,RC,13131,HCPCS,outpatient,,,440,264.00,,535,100,,,fee schedule,100% of asc tier groupings rate,211.2,48,,168.96,percent of total billed charges,48% of total billed charges,220,50,,176,percent of total billed charges,50% of total billed charges,220,50,,176,percent of total billed charges,50% of total billed charges,220,50,,176,percent of total billed charges,50% of total billed charges,220,50,,176,percent of total billed charges,50% of total billed charges,308,70,,246.4,percent of total billed charges,70% of total billed charges,213.31,48.48,,170.648,percent of total billed charges,48.48% of total billed charges,266.84,116.15,,,fee schedule,116.51% of cms physician fee schedule,213.31,48.48,,170.648,percent of total billed charges,48.48% of total billed charges,308,70,,246.4,percent of total billed charges,70% of total billed charges,308,70,,246.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,213.31,48.48,,170.648,percent of total billed charges,48.48% of total billed charges,396,90,,316.8,percent of total billed charges,90% of total billed charges,48.48,396,
INIT TMT 1ST DEGREE BURN,36010025,CDM,450,RC,16000,HCPCS,outpatient,,,353.49,212.09,,212.09,60,,169.672,percent of total billed charges,60% of total billed charges,169.68,48,,135.744,percent of total billed charges,48% of total billed charges,176.75,50,,141.4,percent of total billed charges,50% of total billed charges,176.75,50,,141.4,percent of total billed charges,50% of total billed charges,176.75,50,,141.4,percent of total billed charges,50% of total billed charges,176.75,50,,141.4,percent of total billed charges,50% of total billed charges,247.44,70,,197.952,percent of total billed charges,70% of total billed charges,171.37,48.48,,137.096,percent of total billed charges,48.48% of total billed charges,51.77,116.15,,,fee schedule,116.51% of cms physician fee schedule,171.37,48.48,,137.096,percent of total billed charges,48.48% of total billed charges,247.44,70,,197.952,percent of total billed charges,70% of total billed charges,247.44,70,,197.952,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,171.37,48.48,,137.096,percent of total billed charges,48.48% of total billed charges,318.14,90,,254.512,percent of total billed charges,90% of total billed charges,48.48,318.14,
TRMNT CLOSED SHOULDER DIS,36010036,CDM,450,RC,23650,HCPCS,outpatient,,,348.75,209.25,,399,100,,,fee schedule,100% of asc tier groupings rate,167.4,48,,133.92,percent of total billed charges,48% of total billed charges,559.46,100,,,fee schedule,100% of bcbs custom fee schedule,559.46,100,,,fee schedule,100% of bcbs custom fee schedule,621,111,,,fee schedule,111% of bcbs custom fee schedule,174.38,50,,139.504,percent of total billed charges,50% of total billed charges,244.13,70,,195.304,percent of total billed charges,70% of total billed charges,169.07,48.48,,135.256,percent of total billed charges,48.48% of total billed charges,342.85,116.15,,,fee schedule,116.51% of cms physician fee schedule,169.07,48.48,,135.256,percent of total billed charges,48.48% of total billed charges,244.13,70,,195.304,percent of total billed charges,70% of total billed charges,244.13,70,,195.304,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,169.07,48.48,,135.256,percent of total billed charges,48.48% of total billed charges,313.88,90,,251.104,percent of total billed charges,90% of total billed charges,48.48,313.88,
AVUL NP PAR/CMPL SNGL/SMP,36010009,CDM,450,RC,11730,HCPCS,outpatient,,,202.28,121.37,,399,100,,,fee schedule,100% of asc tier groupings rate,97.09,48,,77.672,percent of total billed charges,48% of total billed charges,172.44,100,,,fee schedule,100% of bcbs custom fee schedule,172.44,100,,,fee schedule,100% of bcbs custom fee schedule,191.41,111,,,fee schedule,111% of bcbs custom fee schedule,101.14,50,,80.912,percent of total billed charges,50% of total billed charges,141.6,70,,113.28,percent of total billed charges,70% of total billed charges,98.07,48.48,,78.456,percent of total billed charges,48.48% of total billed charges,60.15,116.15,,,fee schedule,116.51% of cms physician fee schedule,98.07,48.48,,78.456,percent of total billed charges,48.48% of total billed charges,141.6,70,,113.28,percent of total billed charges,70% of total billed charges,141.6,70,,113.28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,98.07,48.48,,78.456,percent of total billed charges,48.48% of total billed charges,182.05,90,,145.64,percent of total billed charges,90% of total billed charges,48.48,182.05,
I&D FINGER/ABCESS;SMPLE,36011037,CDM,450,RC,26010,HCPCS,outpatient,,,220,132.00,,132,60,,105.6,percent of total billed charges,60% of total billed charges,105.6,48,,84.48,percent of total billed charges,48% of total billed charges,245.57,100,,,fee schedule,100% of bcbs custom fee schedule,245.57,100,,,fee schedule,100% of bcbs custom fee schedule,272.58,111,,,fee schedule,111% of bcbs custom fee schedule,110,50,,88,percent of total billed charges,50% of total billed charges,154,70,,123.2,percent of total billed charges,70% of total billed charges,106.66,48.48,,85.328,percent of total billed charges,48.48% of total billed charges,156.05,116.15,,,fee schedule,116.51% of cms physician fee schedule,106.66,48.48,,85.328,percent of total billed charges,48.48% of total billed charges,154,70,,123.2,percent of total billed charges,70% of total billed charges,154,70,,123.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,106.66,48.48,,85.328,percent of total billed charges,48.48% of total billed charges,198,90,,158.4,percent of total billed charges,90% of total billed charges,48.48,198,
TRMNT CLOSD IP JNT FX DIS,36010063,CDM,450,RC,26770,HCPCS,outpatient,,,338.2,202.92,,202.92,60,,162.336,percent of total billed charges,60% of total billed charges,162.34,48,,129.872,percent of total billed charges,48% of total billed charges,279.73,100,,,fee schedule,100% of bcbs custom fee schedule,279.73,100,,,fee schedule,100% of bcbs custom fee schedule,310.5,111,,,fee schedule,111% of bcbs custom fee schedule,169.1,50,,135.28,percent of total billed charges,50% of total billed charges,236.74,70,,189.392,percent of total billed charges,70% of total billed charges,163.96,48.48,,131.168,percent of total billed charges,48.48% of total billed charges,300.94,116.15,,,fee schedule,116.51% of cms physician fee schedule,163.96,48.48,,131.168,percent of total billed charges,48.48% of total billed charges,236.74,70,,189.392,percent of total billed charges,70% of total billed charges,236.74,70,,189.392,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,163.96,48.48,,131.168,percent of total billed charges,48.48% of total billed charges,304.38,90,,243.504,percent of total billed charges,90% of total billed charges,48.48,304.38,
TRMT CLOSED MP JOINT DIS,36010088,CDM,450,RC,28630,HCPCS,outpatient,,,173.75,104.25,,399,100,,,fee schedule,100% of asc tier groupings rate,83.4,48,,66.72,percent of total billed charges,48% of total billed charges,279.73,100,,,fee schedule,100% of bcbs custom fee schedule,279.73,100,,,fee schedule,100% of bcbs custom fee schedule,310.5,111,,,fee schedule,111% of bcbs custom fee schedule,86.88,50,,69.504,percent of total billed charges,50% of total billed charges,121.63,70,,97.304,percent of total billed charges,70% of total billed charges,84.23,48.48,,67.384,percent of total billed charges,48.48% of total billed charges,125.33,116.15,,,fee schedule,116.51% of cms physician fee schedule,84.23,48.48,,67.384,percent of total billed charges,48.48% of total billed charges,121.63,70,,97.304,percent of total billed charges,70% of total billed charges,121.63,70,,97.304,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,84.23,48.48,,67.384,percent of total billed charges,48.48% of total billed charges,156.38,90,,125.104,percent of total billed charges,90% of total billed charges,48.48,156.38,
APPLI CAST/SHORT ARM,36010133,CDM,450,RC,29075,HCPCS,outpatient,,,401.4,240.84,,240.84,60,,192.672,percent of total billed charges,60% of total billed charges,192.67,48,,154.136,percent of total billed charges,48% of total billed charges,200.7,50,,160.56,percent of total billed charges,50% of total billed charges,200.7,50,,160.56,percent of total billed charges,50% of total billed charges,200.7,50,,160.56,percent of total billed charges,50% of total billed charges,200.7,50,,160.56,percent of total billed charges,50% of total billed charges,280.98,70,,224.784,percent of total billed charges,70% of total billed charges,194.6,48.48,,155.68,percent of total billed charges,48.48% of total billed charges,69.25,116.15,,,fee schedule,116.51% of cms physician fee schedule,194.6,48.48,,155.68,percent of total billed charges,48.48% of total billed charges,280.98,70,,224.784,percent of total billed charges,70% of total billed charges,280.98,70,,224.784,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,194.6,48.48,,155.68,percent of total billed charges,48.48% of total billed charges,361.26,90,,289.008,percent of total billed charges,90% of total billed charges,48.48,361.26,
APP LONG ARM SPLINT,36011049,CDM,450,RC,29105,HCPCS,outpatient,,,147.5,88.50,,88.5,60,,70.8,percent of total billed charges,60% of total billed charges,70.8,48,,56.64,percent of total billed charges,48% of total billed charges,325.87,100,,,fee schedule,100% of bcbs custom fee schedule,325.87,100,,,fee schedule,100% of bcbs custom fee schedule,361.72,111,,,fee schedule,111% of bcbs custom fee schedule,73.75,50,,59,percent of total billed charges,50% of total billed charges,103.25,70,,82.6,percent of total billed charges,70% of total billed charges,71.51,48.48,,57.208,percent of total billed charges,48.48% of total billed charges,47.82,116.15,,,fee schedule,116.51% of cms physician fee schedule,71.51,48.48,,57.208,percent of total billed charges,48.48% of total billed charges,103.25,70,,82.6,percent of total billed charges,70% of total billed charges,103.25,70,,82.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,71.51,48.48,,57.208,percent of total billed charges,48.48% of total billed charges,132.75,90,,106.2,percent of total billed charges,90% of total billed charges,48.48,132.75,
APP SHORT ARM SPLINT STAT,36010311,CDM,450,RC,29125,HCPCS,outpatient,,,131.25,78.75,,78.75,60,,63,percent of total billed charges,60% of total billed charges,63,48,,50.4,percent of total billed charges,48% of total billed charges,249.18,100,,,fee schedule,100% of bcbs custom fee schedule,249.18,100,,,fee schedule,100% of bcbs custom fee schedule,276.59,111,,,fee schedule,111% of bcbs custom fee schedule,65.63,50,,52.504,percent of total billed charges,50% of total billed charges,91.88,70,,73.504,percent of total billed charges,70% of total billed charges,63.63,48.48,,50.904,percent of total billed charges,48.48% of total billed charges,44.65,116.15,,,fee schedule,116.51% of cms physician fee schedule,63.63,48.48,,50.904,percent of total billed charges,48.48% of total billed charges,91.88,70,,73.504,percent of total billed charges,70% of total billed charges,91.88,70,,73.504,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,63.63,48.48,,50.904,percent of total billed charges,48.48% of total billed charges,118.13,90,,94.504,percent of total billed charges,90% of total billed charges,48.48,118.13,
APP SHRT ARM SPNT DYNAMIC,36011039,CDM,450,RC,29126,HCPCS,outpatient,,,165.45,99.27,,99.27,60,,79.416,percent of total billed charges,60% of total billed charges,79.42,48,,63.536,percent of total billed charges,48% of total billed charges,82.73,50,,66.184,percent of total billed charges,50% of total billed charges,82.73,50,,66.184,percent of total billed charges,50% of total billed charges,82.73,50,,66.184,percent of total billed charges,50% of total billed charges,82.73,50,,66.184,percent of total billed charges,50% of total billed charges,115.82,70,,92.656,percent of total billed charges,70% of total billed charges,80.21,48.48,,64.168,percent of total billed charges,48.48% of total billed charges,54.75,116.15,,,fee schedule,116.51% of cms physician fee schedule,80.21,48.48,,64.168,percent of total billed charges,48.48% of total billed charges,115.82,70,,92.656,percent of total billed charges,70% of total billed charges,115.82,70,,92.656,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,80.21,48.48,,64.168,percent of total billed charges,48.48% of total billed charges,148.91,90,,119.128,percent of total billed charges,90% of total billed charges,48.48,148.91,
APP FINGER SPLINT STATIC,36011044,CDM,450,RC,29130,HCPCS,outpatient,,,179.1,107.46,,107.46,60,,85.968,percent of total billed charges,60% of total billed charges,85.97,48,,68.776,percent of total billed charges,48% of total billed charges,152.88,100,,,fee schedule,100% of bcbs custom fee schedule,152.88,100,,,fee schedule,100% of bcbs custom fee schedule,169.7,111,,,fee schedule,111% of bcbs custom fee schedule,89.55,50,,71.64,percent of total billed charges,50% of total billed charges,125.37,70,,100.296,percent of total billed charges,70% of total billed charges,86.83,48.48,,69.464,percent of total billed charges,48.48% of total billed charges,32.79,116.15,,,fee schedule,116.51% of cms physician fee schedule,86.83,48.48,,69.464,percent of total billed charges,48.48% of total billed charges,125.37,70,,100.296,percent of total billed charges,70% of total billed charges,125.37,70,,100.296,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,86.83,48.48,,69.464,percent of total billed charges,48.48% of total billed charges,161.19,90,,128.952,percent of total billed charges,90% of total billed charges,48.48,161.19,
APP LONG LEG SPLINT,36013008,CDM,450,RC,29505,HCPCS,outpatient,,,166.25,99.75,,99.75,60,,79.8,percent of total billed charges,60% of total billed charges,79.8,48,,63.84,percent of total billed charges,48% of total billed charges,325.87,100,,,fee schedule,100% of bcbs custom fee schedule,325.87,100,,,fee schedule,100% of bcbs custom fee schedule,361.72,111,,,fee schedule,111% of bcbs custom fee schedule,83.13,50,,66.504,percent of total billed charges,50% of total billed charges,116.38,70,,93.104,percent of total billed charges,70% of total billed charges,80.6,48.48,,64.48,percent of total billed charges,48.48% of total billed charges,58.06,116.15,,,fee schedule,116.51% of cms physician fee schedule,80.6,48.48,,64.48,percent of total billed charges,48.48% of total billed charges,116.38,70,,93.104,percent of total billed charges,70% of total billed charges,116.38,70,,93.104,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,80.6,48.48,,64.48,percent of total billed charges,48.48% of total billed charges,149.63,90,,119.704,percent of total billed charges,90% of total billed charges,48.48,149.63,
APP SHORT LEG SPLINT,36011056,CDM,450,RC,29515,HCPCS,outpatient,,,131.25,78.75,,78.75,60,,63,percent of total billed charges,60% of total billed charges,63,48,,50.4,percent of total billed charges,48% of total billed charges,325.87,100,,,fee schedule,100% of bcbs custom fee schedule,325.87,100,,,fee schedule,100% of bcbs custom fee schedule,361.72,111,,,fee schedule,111% of bcbs custom fee schedule,65.63,50,,52.504,percent of total billed charges,50% of total billed charges,91.88,70,,73.504,percent of total billed charges,70% of total billed charges,63.63,48.48,,50.904,percent of total billed charges,48.48% of total billed charges,55.44,116.15,,,fee schedule,116.51% of cms physician fee schedule,63.63,48.48,,50.904,percent of total billed charges,48.48% of total billed charges,91.88,70,,73.504,percent of total billed charges,70% of total billed charges,91.88,70,,73.504,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,63.63,48.48,,50.904,percent of total billed charges,48.48% of total billed charges,118.13,90,,94.504,percent of total billed charges,90% of total billed charges,48.48,118.13,
REMOVAL FB INTRANASAL,36010090,CDM,450,RC,30300,HCPCS,outpatient,,,218.75,131.25,,131.25,60,,105,percent of total billed charges,60% of total billed charges,105,48,,84,percent of total billed charges,48% of total billed charges,99.8,100,,,fee schedule,100% of bcbs custom fee schedule,99.8,100,,,fee schedule,100% of bcbs custom fee schedule,110.78,111,,,fee schedule,111% of bcbs custom fee schedule,109.38,50,,87.504,percent of total billed charges,50% of total billed charges,153.13,70,,122.504,percent of total billed charges,70% of total billed charges,106.05,48.48,,84.84,percent of total billed charges,48.48% of total billed charges,132.88,116.15,,,fee schedule,116.51% of cms physician fee schedule,106.05,48.48,,84.84,percent of total billed charges,48.48% of total billed charges,153.13,70,,122.504,percent of total billed charges,70% of total billed charges,153.13,70,,122.504,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,106.05,48.48,,84.84,percent of total billed charges,48.48% of total billed charges,196.88,90,,157.504,percent of total billed charges,90% of total billed charges,48.48,196.88,
CONTROL NOSEBLEED ANT/SMP,36010091,CDM,450,RC,30901,HCPCS,outpatient,,,131.25,78.75,,399,100,,,fee schedule,100% of asc tier groupings rate,63,48,,50.4,percent of total billed charges,48% of total billed charges,199.08,100,,,fee schedule,100% of bcbs custom fee schedule,199.08,100,,,fee schedule,100% of bcbs custom fee schedule,220.98,111,,,fee schedule,111% of bcbs custom fee schedule,65.63,50,,52.504,percent of total billed charges,50% of total billed charges,91.88,70,,73.504,percent of total billed charges,70% of total billed charges,63.63,48.48,,50.904,percent of total billed charges,48.48% of total billed charges,64.47,116.15,,,fee schedule,116.51% of cms physician fee schedule,63.63,48.48,,50.904,percent of total billed charges,48.48% of total billed charges,91.88,70,,73.504,percent of total billed charges,70% of total billed charges,91.88,70,,73.504,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,63.63,48.48,,50.904,percent of total billed charges,48.48% of total billed charges,118.13,90,,94.504,percent of total billed charges,90% of total billed charges,48.48,118.13,
INTUBATION ET,36010097,CDM,450,RC,31500,HCPCS,outpatient,,,261.25,156.75,,399,100,,,fee schedule,100% of asc tier groupings rate,125.4,48,,100.32,percent of total billed charges,48% of total billed charges,399.79,100,,,fee schedule,100% of bcbs custom fee schedule,399.79,100,,,fee schedule,100% of bcbs custom fee schedule,443.77,111,,,fee schedule,111% of bcbs custom fee schedule,130.63,50,,104.504,percent of total billed charges,50% of total billed charges,182.88,70,,146.304,percent of total billed charges,70% of total billed charges,126.65,48.48,,101.32,percent of total billed charges,48.48% of total billed charges,160.07,116.15,,,fee schedule,116.51% of cms physician fee schedule,126.65,48.48,,101.32,percent of total billed charges,48.48% of total billed charges,182.88,70,,146.304,percent of total billed charges,70% of total billed charges,182.88,70,,146.304,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,126.65,48.48,,101.32,percent of total billed charges,48.48% of total billed charges,235.13,90,,188.104,percent of total billed charges,90% of total billed charges,48.48,235.13,
CHEST TUBE PLACEMENT,36010098,CDM,450,RC,32551,HCPCS,outpatient,,,566.25,339.75,,535,100,,,fee schedule,100% of asc tier groupings rate,271.8,48,,217.44,percent of total billed charges,48% of total billed charges,905.56,100,,,fee schedule,100% of bcbs custom fee schedule,905.56,100,,,fee schedule,100% of bcbs custom fee schedule,1005.17,111,,,fee schedule,111% of bcbs custom fee schedule,283.13,50,,226.504,percent of total billed charges,50% of total billed charges,396.38,70,,317.104,percent of total billed charges,70% of total billed charges,274.52,48.48,,219.616,percent of total billed charges,48.48% of total billed charges,175.51,116.15,,,fee schedule,116.51% of cms physician fee schedule,274.52,48.48,,219.616,percent of total billed charges,48.48% of total billed charges,396.38,70,,317.104,percent of total billed charges,70% of total billed charges,396.38,70,,317.104,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,274.52,48.48,,219.616,percent of total billed charges,48.48% of total billed charges,509.63,90,,407.704,percent of total billed charges,90% of total billed charges,48.48,509.63,
CENTRAL LINE PLACEMENT,,,450,RC,36011,HCPCS,outpatient,,,566.25,339.75,,399,100,,,fee schedule,100% of asc tier groupings rate,271.8,48,,217.44,percent of total billed charges,48% of total billed charges,944.62,100,,,fee schedule,100% of bcbs custom fee schedule,944.62,100,,,fee schedule,100% of bcbs custom fee schedule,1048.53,111,,,fee schedule,111% of bcbs custom fee schedule,283.13,50,,226.504,percent of total billed charges,50% of total billed charges,396.38,70,,317.104,percent of total billed charges,70% of total billed charges,274.52,48.48,,219.616,percent of total billed charges,48.48% of total billed charges,174.54,116.15,,,fee schedule,116.51% of cms physician fee schedule,274.52,48.48,,219.616,percent of total billed charges,48.48% of total billed charges,396.38,70,,317.104,percent of total billed charges,70% of total billed charges,396.38,70,,317.104,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,274.52,48.48,,219.616,percent of total billed charges,48.48% of total billed charges,509.63,90,,407.704,percent of total billed charges,90% of total billed charges,48.48,509.63,
Pleural Catheter Insertion,,,761,RC,32550,HCPCS,outpatient,,,623.43,374.06,,535,100,,,fee schedule,100% of asc tier groupings rate,299.25,48,,239.4,percent of total billed charges,48% of total billed charges,5345.56,100,,,fee schedule,100% of bcbs custom fee schedule,5345.56,100,,,fee schedule,100% of bcbs custom fee schedule,5933.57,111,,,fee schedule,111% of bcbs custom fee schedule,311.72,50,,249.376,percent of total billed charges,50% of total billed charges,436.4,70,,349.12,percent of total billed charges,70% of total billed charges,302.24,48.48,,241.792,percent of total billed charges,48.48% of total billed charges,227.6,116.15,,,fee schedule,116.51% of cms physician fee schedule,302.24,48.48,,241.792,percent of total billed charges,48.48% of total billed charges,436.4,70,,349.12,percent of total billed charges,70% of total billed charges,436.4,70,,349.12,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,302.24,48.48,,241.792,percent of total billed charges,48.48% of total billed charges,561.09,90,,448.872,percent of total billed charges,90% of total billed charges,48.48,561.09,
Pleural Catheter Insertion,,,960,RC,32550,HCPCS,outpatient,,,623.43,374.06,,,,,,other,not separately reimbusable,195.95,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,372.03,100,,,fee schedule,100% of cigna custom fee schedule,215.55,110,,,fee schedule,110% of cms physician fee schedule,197.91,101,,,fee schedule,101% of cms physician fee schedule ,197.91,116.15,,,fee schedule,116.51% of cms physician fee schedule,197.91,101,,,fee schedule,101% of cms physician fee schedule,372.31,110,,,fee schedule,110% of humana physician fee schedule,215.55,110,,,fee schedule,110% of humana physician fee schedule,293.93,150,,,fee schedule,100% of cms fee schedule,195.95,100,,,fee schedule,100% of cms physician fee schedule,293.93,150,,,fee schedule,150% of cms physician fee schedule,100,293.93,
INSERT PICC CATH,36010102,CDM,450,RC,36556,HCPCS,outpatient,,,1175,705.00,,399,100,,,fee schedule,100% of asc tier groupings rate,564,48,,451.2,percent of total billed charges,48% of total billed charges,1338.69,100,,,fee schedule,100% of bcbs custom fee schedule,1338.69,100,,,fee schedule,100% of bcbs custom fee schedule,1485.95,111,,,fee schedule,111% of bcbs custom fee schedule,587.5,50,,470,percent of total billed charges,50% of total billed charges,822.5,70,,658,percent of total billed charges,70% of total billed charges,569.64,48.48,,455.712,percent of total billed charges,48.48% of total billed charges,95.1,116.15,,,fee schedule,116.51% of cms physician fee schedule,569.64,48.48,,455.712,percent of total billed charges,48.48% of total billed charges,822.5,70,,658,percent of total billed charges,70% of total billed charges,822.5,70,,658,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,569.64,48.48,,455.712,percent of total billed charges,48.48% of total billed charges,1057.5,90,,846,percent of total billed charges,90% of total billed charges,48.48,1057.5,
BIOPSY OF LIP,,,450,RC,40490,HCPCS,outpatient,,,546.13,327.68,,327.68,60,,262.144,percent of total billed charges,60% of total billed charges,262.14,48,,209.712,percent of total billed charges,48% of total billed charges,338.1,100,,,fee schedule,100% of bcbs custom fee schedule,338.1,100,,,fee schedule,100% of bcbs custom fee schedule,375.29,111,,,fee schedule,111% of bcbs custom fee schedule,273.07,50,,218.456,percent of total billed charges,50% of total billed charges,382.29,70,,305.832,percent of total billed charges,70% of total billed charges,264.76,48.48,,211.808,percent of total billed charges,48.48% of total billed charges,76.96,116.15,,,fee schedule,116.51% of cms physician fee schedule,264.76,48.48,,211.808,percent of total billed charges,48.48% of total billed charges,382.29,70,,305.832,percent of total billed charges,70% of total billed charges,382.29,70,,305.832,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,264.76,48.48,,211.808,percent of total billed charges,48.48% of total billed charges,491.52,90,,393.216,percent of total billed charges,90% of total billed charges,48.48,491.52,
REP LAC MOUTH/2/3TNG 2.5<,36010300,CDM,450,RC,41250,HCPCS,outpatient,,,215,129.00,,535,100,,,fee schedule,100% of asc tier groupings rate,103.2,48,,82.56,percent of total billed charges,48% of total billed charges,338.1,100,,,fee schedule,100% of bcbs custom fee schedule,338.1,100,,,fee schedule,100% of bcbs custom fee schedule,375.29,111,,,fee schedule,111% of bcbs custom fee schedule,107.5,50,,86,percent of total billed charges,50% of total billed charges,150.5,70,,120.4,percent of total billed charges,70% of total billed charges,104.23,48.48,,83.384,percent of total billed charges,48.48% of total billed charges,170.48,116.15,,,fee schedule,116.51% of cms physician fee schedule,104.23,48.48,,83.384,percent of total billed charges,48.48% of total billed charges,150.5,70,,120.4,percent of total billed charges,70% of total billed charges,150.5,70,,120.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,104.23,48.48,,83.384,percent of total billed charges,48.48% of total billed charges,193.5,90,,154.8,percent of total billed charges,90% of total billed charges,48.48,193.5,
PLCMNT NASO/ORO-GAST TUBE,,,450,RC,43752,HCPCS,outpatient,,,218.75,131.25,,535,100,,,fee schedule,100% of asc tier groupings rate,105,48,,84,percent of total billed charges,48% of total billed charges,216.16,100,,,fee schedule,100% of bcbs custom fee schedule,216.16,100,,,fee schedule,100% of bcbs custom fee schedule,239.94,111,,,fee schedule,111% of bcbs custom fee schedule,109.38,50,,87.504,percent of total billed charges,50% of total billed charges,153.13,70,,122.504,percent of total billed charges,70% of total billed charges,106.05,48.48,,84.84,percent of total billed charges,48.48% of total billed charges,44.88,116.15,,,fee schedule,116.51% of cms physician fee schedule,106.05,48.48,,84.84,percent of total billed charges,48.48% of total billed charges,153.13,70,,122.504,percent of total billed charges,70% of total billed charges,153.13,70,,122.504,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,106.05,48.48,,84.84,percent of total billed charges,48.48% of total billed charges,196.88,90,,157.504,percent of total billed charges,90% of total billed charges,48.48,196.88,
INSERT TEMP INDWLN CATH,36011020,CDM,450,RC,51702,HCPCS,outpatient,,,218.75,131.25,,399,100,,,fee schedule,100% of asc tier groupings rate,105,48,,84,percent of total billed charges,48% of total billed charges,99.81,100,,,fee schedule,100% of bcbs custom fee schedule,99.81,100,,,fee schedule,100% of bcbs custom fee schedule,110.79,111,,,fee schedule,111% of bcbs custom fee schedule,109.38,50,,87.504,percent of total billed charges,50% of total billed charges,153.13,70,,122.504,percent of total billed charges,70% of total billed charges,106.05,48.48,,84.84,percent of total billed charges,48.48% of total billed charges,28.41,116.15,,,fee schedule,116.51% of cms physician fee schedule,106.05,48.48,,84.84,percent of total billed charges,48.48% of total billed charges,153.13,70,,122.504,percent of total billed charges,70% of total billed charges,153.13,70,,122.504,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,106.05,48.48,,84.84,percent of total billed charges,48.48% of total billed charges,196.88,90,,157.504,percent of total billed charges,90% of total billed charges,48.48,196.88,
INSERT BLADDER CATHETER,,,450,RC,51701,HCPCS,outpatient,,,201.25,120.75,,399,100,,,fee schedule,100% of asc tier groupings rate,96.6,48,,77.28,percent of total billed charges,48% of total billed charges,99.81,100,,,fee schedule,100% of bcbs custom fee schedule,99.81,100,,,fee schedule,100% of bcbs custom fee schedule,110.79,111,,,fee schedule,111% of bcbs custom fee schedule,100.63,50,,80.504,percent of total billed charges,50% of total billed charges,140.88,70,,112.704,percent of total billed charges,70% of total billed charges,97.57,48.48,,78.056,percent of total billed charges,48.48% of total billed charges,28.85,116.15,,,fee schedule,116.51% of cms physician fee schedule,97.57,48.48,,78.056,percent of total billed charges,48.48% of total billed charges,140.88,70,,112.704,percent of total billed charges,70% of total billed charges,140.88,70,,112.704,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,97.57,48.48,,78.056,percent of total billed charges,48.48% of total billed charges,181.13,90,,144.904,percent of total billed charges,90% of total billed charges,48.48,181.13,
SPINAL PUNCTURE LUMBAR DX,36009170,CDM,450,RC,62270,HCPCS,outpatient,,,402.5,241.50,,399,100,,,fee schedule,100% of asc tier groupings rate,193.2,48,,154.56,percent of total billed charges,48% of total billed charges,368.64,100,,,fee schedule,100% of bcbs custom fee schedule,368.64,100,,,fee schedule,100% of bcbs custom fee schedule,409.19,111,,,fee schedule,111% of bcbs custom fee schedule,201.25,50,,161,percent of total billed charges,50% of total billed charges,281.75,70,,225.4,percent of total billed charges,70% of total billed charges,195.13,48.48,,156.104,percent of total billed charges,48.48% of total billed charges,72.99,116.15,,,fee schedule,116.51% of cms physician fee schedule,195.13,48.48,,156.104,percent of total billed charges,48.48% of total billed charges,281.75,70,,225.4,percent of total billed charges,70% of total billed charges,281.75,70,,225.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,195.13,48.48,,156.104,percent of total billed charges,48.48% of total billed charges,362.25,90,,289.8,percent of total billed charges,90% of total billed charges,48.48,362.25,
"RMVL FB EXT EYE CONJ,SMPL",36010108,CDM,450,RC,65205,HCPCS,outpatient,,,261.25,156.75,,156.75,60,,125.4,percent of total billed charges,60% of total billed charges,125.4,48,,100.32,percent of total billed charges,48% of total billed charges,201.3,100,,,fee schedule,100% of bcbs custom fee schedule,201.3,100,,,fee schedule,100% of bcbs custom fee schedule,223.44,111,,,fee schedule,111% of bcbs custom fee schedule,130.63,50,,104.504,percent of total billed charges,50% of total billed charges,182.88,70,,146.304,percent of total billed charges,70% of total billed charges,126.65,48.48,,101.32,percent of total billed charges,48.48% of total billed charges,31.78,116.15,,,fee schedule,116.51% of cms physician fee schedule,126.65,48.48,,101.32,percent of total billed charges,48.48% of total billed charges,182.88,70,,146.304,percent of total billed charges,70% of total billed charges,182.88,70,,146.304,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,126.65,48.48,,101.32,percent of total billed charges,48.48% of total billed charges,235.13,90,,188.104,percent of total billed charges,90% of total billed charges,48.48,235.13,
I&D EXT EAR ABSCESS;SMPL,36010205,CDM,450,RC,69000,HCPCS,outpatient,,,218.75,131.25,,399,100,,,fee schedule,100% of asc tier groupings rate,105,48,,84,percent of total billed charges,48% of total billed charges,245.57,100,,,fee schedule,100% of bcbs custom fee schedule,245.57,100,,,fee schedule,100% of bcbs custom fee schedule,272.58,111,,,fee schedule,111% of bcbs custom fee schedule,109.38,50,,87.504,percent of total billed charges,50% of total billed charges,153.13,70,,122.504,percent of total billed charges,70% of total billed charges,106.05,48.48,,84.84,percent of total billed charges,48.48% of total billed charges,138.28,116.15,,,fee schedule,116.51% of cms physician fee schedule,106.05,48.48,,84.84,percent of total billed charges,48.48% of total billed charges,153.13,70,,122.504,percent of total billed charges,70% of total billed charges,153.13,70,,122.504,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,106.05,48.48,,84.84,percent of total billed charges,48.48% of total billed charges,196.88,90,,157.504,percent of total billed charges,90% of total billed charges,48.48,196.88,
RMVL FB EXTRNL AUD CANAL,36010127,CDM,450,RC,69200,HCPCS,outpatient,,,221.25,132.75,,132.75,60,,106.2,percent of total billed charges,60% of total billed charges,106.2,48,,84.96,percent of total billed charges,48% of total billed charges,99.8,100,,,fee schedule,100% of bcbs custom fee schedule,99.8,100,,,fee schedule,100% of bcbs custom fee schedule,110.78,111,,,fee schedule,111% of bcbs custom fee schedule,110.63,50,,88.504,percent of total billed charges,50% of total billed charges,154.88,70,,123.904,percent of total billed charges,70% of total billed charges,107.26,48.48,,85.808,percent of total billed charges,48.48% of total billed charges,52.92,116.15,,,fee schedule,116.51% of cms physician fee schedule,107.26,48.48,,85.808,percent of total billed charges,48.48% of total billed charges,154.88,70,,123.904,percent of total billed charges,70% of total billed charges,154.88,70,,123.904,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,107.26,48.48,,85.808,percent of total billed charges,48.48% of total billed charges,199.13,90,,159.304,percent of total billed charges,90% of total billed charges,48.48,199.13,
REM IMPACT CERUMEN UNILAT,36010128,CDM,450,RC,69210,HCPCS,outpatient,,,87.5,52.50,,399,100,,,fee schedule,100% of asc tier groupings rate,42,48,,33.6,percent of total billed charges,48% of total billed charges,99.8,100,,,fee schedule,100% of bcbs custom fee schedule,99.8,100,,,fee schedule,100% of bcbs custom fee schedule,110.78,111,,,fee schedule,111% of bcbs custom fee schedule,43.75,50,,35,percent of total billed charges,50% of total billed charges,61.25,70,,49,percent of total billed charges,70% of total billed charges,42.42,48.48,,33.936,percent of total billed charges,48.48% of total billed charges,36.6,116.15,,,fee schedule,116.51% of cms physician fee schedule,42.42,48.48,,33.936,percent of total billed charges,48.48% of total billed charges,61.25,70,,49,percent of total billed charges,70% of total billed charges,61.25,70,,49,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,42.42,48.48,,33.936,percent of total billed charges,48.48% of total billed charges,78.75,90,,63,percent of total billed charges,90% of total billed charges,42.42,90,
CPR,36010117,CDM,450,RC,92950,HCPCS,outpatient,,,820.28,492.17,,492.17,60,,393.736,percent of total billed charges,60% of total billed charges,393.73,48,,314.984,percent of total billed charges,48% of total billed charges,399.79,100,,,fee schedule,100% of bcbs custom fee schedule,399.79,100,,,fee schedule,100% of bcbs custom fee schedule,443.77,111,,,fee schedule,111% of bcbs custom fee schedule,410.14,50,,328.112,percent of total billed charges,50% of total billed charges,574.2,70,,459.36,percent of total billed charges,70% of total billed charges,397.67,48.48,,318.136,percent of total billed charges,48.48% of total billed charges,206.55,116.15,,,fee schedule,116.51% of cms physician fee schedule,397.67,48.48,,318.136,percent of total billed charges,48.48% of total billed charges,574.2,70,,459.36,percent of total billed charges,70% of total billed charges,574.2,70,,459.36,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,397.67,48.48,,318.136,percent of total billed charges,48.48% of total billed charges,738.25,90,,590.6,percent of total billed charges,90% of total billed charges,48.48,738.25,
CARDIOVERSION,35000029,CDM,450,RC,92960,HCPCS,outpatient,,,904.7,542.82,,542.82,60,,434.256,percent of total billed charges,60% of total billed charges,434.26,48,,347.408,percent of total billed charges,48% of total billed charges,894.36,100,,,fee schedule,100% of bcbs custom fee schedule,894.36,100,,,fee schedule,100% of bcbs custom fee schedule,992.74,111,,,fee schedule,111% of bcbs custom fee schedule,452.35,50,,361.88,percent of total billed charges,50% of total billed charges,633.29,70,,506.632,percent of total billed charges,70% of total billed charges,438.6,48.48,,350.88,percent of total billed charges,48.48% of total billed charges,118.84,116.15,,,fee schedule,116.51% of cms physician fee schedule,438.6,48.48,,350.88,percent of total billed charges,48.48% of total billed charges,633.29,70,,506.632,percent of total billed charges,70% of total billed charges,633.29,70,,506.632,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,438.6,48.48,,350.88,percent of total billed charges,48.48% of total billed charges,814.23,90,,651.384,percent of total billed charges,90% of total billed charges,48.48,814.23,
CRITICAL CARE 30-74 MIN,32009062,CDM,450,RC,99291,HCPCS,outpatient,,,937.5,562.50,,468.75,60,,375,percent of total billed charges,60% of total billed charges,450,48,,360,percent of total billed charges,48% of total billed charges,1051.11,100,,,fee schedule,100% of bcbs custom fee schedule,1051.11,100,,,fee schedule,100% of bcbs custom fee schedule,1166.73,111,,,fee schedule,111% of bcbs custom fee schedule,450,100,,,case rate,pays based on per visit rate,656.25,70,,525,percent of total billed charges,70% of total billed charges,454.5,48.48,,363.6,percent of total billed charges,48.48% of total billed charges,239.63,116.15,,,fee schedule,116.51% of cms physician fee schedule,454.5,48.48,,363.6,percent of total billed charges,48.48% of total billed charges,656.25,70,,525,percent of total billed charges,70% of total billed charges,656.25,70,,525,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,454.5,48.48,,363.6,percent of total billed charges,48.48% of total billed charges,843.75,90,,675,percent of total billed charges,90% of total billed charges,48.48,843.75,
CRITICAL CARE ADD 30 MIN,32009063,CDM,450,RC,99292,HCPCS,outpatient,,,261.25,156.75,,130.63,60,,104.504,percent of total billed charges,60% of total billed charges,125.4,48,,100.32,percent of total billed charges,48% of total billed charges,722.7,100,,,fee schedule,100% of bcbs custom fee schedule,722.7,100,,,fee schedule,100% of bcbs custom fee schedule,802.2,111,,,fee schedule,111% of bcbs custom fee schedule,450,100,,,case rate,pays based on per visit rate,182.88,70,,146.304,percent of total billed charges,70% of total billed charges,126.65,48.48,,101.32,percent of total billed charges,48.48% of total billed charges,120.87,116.15,,,fee schedule,116.51% of cms physician fee schedule,126.65,48.48,,101.32,percent of total billed charges,48.48% of total billed charges,182.88,70,,146.304,percent of total billed charges,70% of total billed charges,182.88,70,,146.304,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,126.65,48.48,,101.32,percent of total billed charges,48.48% of total billed charges,235.13,90,,188.104,percent of total billed charges,90% of total billed charges,48.48,235.13,
Complex Repair - Integumentary,36010193,CDM,450,RC,13133,HCPCS,outpatient,,,440,264.00,,399,100,,,fee schedule,100% of asc tier groupings rate,211.2,48,,168.96,percent of total billed charges,48% of total billed charges,220,50,,176,percent of total billed charges,50% of total billed charges,220,50,,176,percent of total billed charges,50% of total billed charges,220,50,,176,percent of total billed charges,50% of total billed charges,220,50,,176,percent of total billed charges,50% of total billed charges,308,70,,246.4,percent of total billed charges,70% of total billed charges,213.31,48.48,,170.648,percent of total billed charges,48.48% of total billed charges,139.5,116.15,,,fee schedule,116.51% of cms physician fee schedule,213.31,48.48,,170.648,percent of total billed charges,48.48% of total billed charges,308,70,,246.4,percent of total billed charges,70% of total billed charges,308,70,,246.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,213.31,48.48,,170.648,percent of total billed charges,48.48% of total billed charges,396,90,,316.8,percent of total billed charges,90% of total billed charges,48.48,396,
CMPLX REPR S/A/L;2.6-7.5,36010134,CDM,450,RC,13121,HCPCS,outpatient,,,478.75,287.25,,612,100,,,fee schedule,100% of asc tier groupings rate,229.8,48,,183.84,percent of total billed charges,48% of total billed charges,1171.5,100,,,fee schedule,100% of bcbs custom fee schedule,1171.5,100,,,fee schedule,100% of bcbs custom fee schedule,1300.37,111,,,fee schedule,111% of bcbs custom fee schedule,239.38,50,,191.504,percent of total billed charges,50% of total billed charges,335.13,70,,268.104,percent of total billed charges,70% of total billed charges,232.1,48.48,,185.68,percent of total billed charges,48.48% of total billed charges,284.16,116.15,,,fee schedule,116.51% of cms physician fee schedule,232.1,48.48,,185.68,percent of total billed charges,48.48% of total billed charges,335.13,70,,268.104,percent of total billed charges,70% of total billed charges,335.13,70,,268.104,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,232.1,48.48,,185.68,percent of total billed charges,48.48% of total billed charges,430.88,90,,344.704,percent of total billed charges,90% of total billed charges,48.48,430.88,
IV INFUS THER EA ADD'L HR,32000014,CDM,260,RC,96366,HCPCS,outpatient,,,135,81.00,,81,60,,64.8,percent of total billed charges,60% of total billed charges,64.8,48,,51.84,percent of total billed charges,48% of total billed charges,105.22,100,,,fee schedule,100% of bcbs custom fee schedule,105.22,100,,,fee schedule,100% of bcbs custom fee schedule,116.79,111,,,fee schedule,111% of bcbs custom fee schedule,67.5,50,,54,percent of total billed charges,50% of total billed charges,94.5,70,,75.6,percent of total billed charges,70% of total billed charges,65.45,48.48,,52.36,percent of total billed charges,48.48% of total billed charges,21.62,116.15,,,fee schedule,116.51% of cms physician fee schedule,65.45,48.48,,52.36,percent of total billed charges,48.48% of total billed charges,94.5,70,,75.6,percent of total billed charges,70% of total billed charges,94.5,70,,75.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,65.45,48.48,,52.36,percent of total billed charges,48.48% of total billed charges,121.5,90,,97.2,percent of total billed charges,90% of total billed charges,48.48,121.5,
I&D ABCESS SINGLE/SIMPLE,36010135,CDM,450,RC,10060,HCPCS,outpatient,,,353.49,212.09,,399,100,,,fee schedule,100% of asc tier groupings rate,169.68,48,,135.744,percent of total billed charges,48% of total billed charges,322.02,100,,,fee schedule,100% of bcbs custom fee schedule,322.02,100,,,fee schedule,100% of bcbs custom fee schedule,357.44,111,,,fee schedule,111% of bcbs custom fee schedule,176.75,50,,141.4,percent of total billed charges,50% of total billed charges,247.44,70,,197.952,percent of total billed charges,70% of total billed charges,171.37,48.48,,137.096,percent of total billed charges,48.48% of total billed charges,116.25,116.15,,,fee schedule,116.51% of cms physician fee schedule,171.37,48.48,,137.096,percent of total billed charges,48.48% of total billed charges,247.44,70,,197.952,percent of total billed charges,70% of total billed charges,247.44,70,,197.952,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,171.37,48.48,,137.096,percent of total billed charges,48.48% of total billed charges,318.14,90,,254.512,percent of total billed charges,90% of total billed charges,48.48,318.14,
CLOSED TX PATELLAR DISLOCATION,36010071,CDM,450,RC,27560,HCPCS,outpatient,,,462.5,277.50,,399,100,,,fee schedule,100% of asc tier groupings rate,222,48,,177.6,percent of total billed charges,48% of total billed charges,559.46,100,,,fee schedule,100% of bcbs custom fee schedule,559.46,100,,,fee schedule,100% of bcbs custom fee schedule,621,111,,,fee schedule,111% of bcbs custom fee schedule,231.25,50,,185,percent of total billed charges,50% of total billed charges,323.75,70,,259,percent of total billed charges,70% of total billed charges,224.22,48.48,,179.376,percent of total billed charges,48.48% of total billed charges,387.99,116.15,,,fee schedule,116.51% of cms physician fee schedule,224.22,48.48,,179.376,percent of total billed charges,48.48% of total billed charges,323.75,70,,259,percent of total billed charges,70% of total billed charges,323.75,70,,259,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,224.22,48.48,,179.376,percent of total billed charges,48.48% of total billed charges,416.25,90,,333,percent of total billed charges,90% of total billed charges,48.48,416.25,
CHANGE GASTROSTOMY TUBE,36010216,CDM,450,RC,43760,HCPCS,outpatient,,,725,435.00,,435,60,,348,percent of total billed charges,60% of total billed charges,348,48,,278.4,percent of total billed charges,48% of total billed charges,362.5,50,,290,percent of total billed charges,50% of total billed charges,362.5,50,,290,percent of total billed charges,50% of total billed charges,362.5,50,,290,percent of total billed charges,50% of total billed charges,362.5,50,,290,percent of total billed charges,50% of total billed charges,507.5,70,,406,percent of total billed charges,70% of total billed charges,351.48,48.48,,281.184,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,351.48,48.48,,281.184,percent of total billed charges,48.48% of total billed charges,507.5,70,,406,percent of total billed charges,70% of total billed charges,507.5,70,,406,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,351.48,48.48,,281.184,percent of total billed charges,48.48% of total billed charges,652.5,90,,522,percent of total billed charges,90% of total billed charges,48.48,652.5,
IRRIGATION OF CORPORA CAVERNOSA,,,450,RC,54220,HCPCS,outpatient,,,626.58,375.95,,399,100,,,fee schedule,100% of asc tier groupings rate,300.76,48,,240.608,percent of total billed charges,48% of total billed charges,424.85,100,,,fee schedule,100% of bcbs custom fee schedule,424.85,100,,,fee schedule,100% of bcbs custom fee schedule,471.58,111,,,fee schedule,111% of bcbs custom fee schedule,313.29,50,,250.632,percent of total billed charges,50% of total billed charges,438.61,70,,350.888,percent of total billed charges,70% of total billed charges,303.77,48.48,,243.016,percent of total billed charges,48.48% of total billed charges,151.89,116.15,,,fee schedule,116.51% of cms physician fee schedule,303.77,48.48,,243.016,percent of total billed charges,48.48% of total billed charges,438.61,70,,350.888,percent of total billed charges,70% of total billed charges,438.61,70,,350.888,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,303.77,48.48,,243.016,percent of total billed charges,48.48% of total billed charges,563.92,90,,451.136,percent of total billed charges,90% of total billed charges,48.48,563.92,
INJ/ASP MAJOR JOINT,35010107,CDM,450,RC,20610,HCPCS,outpatient,,,560.94,336.56,,399,100,,,fee schedule,100% of asc tier groupings rate,269.25,48,,215.4,percent of total billed charges,48% of total billed charges,368.64,100,,,fee schedule,100% of bcbs custom fee schedule,368.64,100,,,fee schedule,100% of bcbs custom fee schedule,409.19,111,,,fee schedule,111% of bcbs custom fee schedule,280.47,50,,224.376,percent of total billed charges,50% of total billed charges,392.66,70,,314.128,percent of total billed charges,70% of total billed charges,271.94,48.48,,217.552,percent of total billed charges,48.48% of total billed charges,51.19,116.15,,,fee schedule,116.51% of cms physician fee schedule,271.94,48.48,,217.552,percent of total billed charges,48.48% of total billed charges,392.66,70,,314.128,percent of total billed charges,70% of total billed charges,392.66,70,,314.128,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,271.94,48.48,,217.552,percent of total billed charges,48.48% of total billed charges,504.85,90,,403.88,percent of total billed charges,90% of total billed charges,48.48,504.85,
TREAT LOWER LEG FRACTURE,,,450,RC,27825,HCPCS,outpatient,,,953.95,572.37,,535,100,,,fee schedule,100% of asc tier groupings rate,457.9,48,,366.32,percent of total billed charges,48% of total billed charges,559.46,100,,,fee schedule,100% of bcbs custom fee schedule,559.46,100,,,fee schedule,100% of bcbs custom fee schedule,621,111,,,fee schedule,111% of bcbs custom fee schedule,476.98,50,,381.584,percent of total billed charges,50% of total billed charges,667.77,70,,534.216,percent of total billed charges,70% of total billed charges,462.47,48.48,,369.976,percent of total billed charges,48.48% of total billed charges,558.18,116.15,,,fee schedule,116.51% of cms physician fee schedule,462.47,48.48,,369.976,percent of total billed charges,48.48% of total billed charges,667.77,70,,534.216,percent of total billed charges,70% of total billed charges,667.77,70,,534.216,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,462.47,48.48,,369.976,percent of total billed charges,48.48% of total billed charges,858.56,90,,686.848,percent of total billed charges,90% of total billed charges,48.48,858.56,
TREAT RADIUS/ULNA FRACTURE,36010048,CDM,450,RC,25605,HCPCS,outpatient,,,1562.58,937.55,,612,100,,,fee schedule,100% of asc tier groupings rate,750.04,48,,600.032,percent of total billed charges,48% of total billed charges,559.46,100,,,fee schedule,100% of bcbs custom fee schedule,559.46,100,,,fee schedule,100% of bcbs custom fee schedule,621,111,,,fee schedule,111% of bcbs custom fee schedule,781.29,50,,625.032,percent of total billed charges,50% of total billed charges,1093.81,70,,875.048,percent of total billed charges,70% of total billed charges,757.54,48.48,,606.032,percent of total billed charges,48.48% of total billed charges,579.03,116.15,,,fee schedule,116.51% of cms physician fee schedule,757.54,48.48,,606.032,percent of total billed charges,48.48% of total billed charges,1093.81,70,,875.048,percent of total billed charges,70% of total billed charges,1093.81,70,,875.048,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,757.54,48.48,,606.032,percent of total billed charges,48.48% of total billed charges,1406.32,90,,1125.056,percent of total billed charges,90% of total billed charges,48.48,1406.32,
SHAVE BX SINGLE LESION,43601381,CDM,450,RC,11102,HCPCS,outpatient,,,381.5,228.90,,399,100,,,fee schedule,100% of asc tier groupings rate,183.12,48,,146.496,percent of total billed charges,48% of total billed charges,482.21,100,,,fee schedule,100% of bcbs custom fee schedule,482.21,100,,,fee schedule,100% of bcbs custom fee schedule,535.25,111,,,fee schedule,111% of bcbs custom fee schedule,190.75,50,,152.6,percent of total billed charges,50% of total billed charges,267.05,70,,213.64,percent of total billed charges,70% of total billed charges,184.95,48.48,,147.96,percent of total billed charges,48.48% of total billed charges,41.81,116.15,,,fee schedule,116.51% of cms physician fee schedule,184.95,48.48,,147.96,percent of total billed charges,48.48% of total billed charges,267.05,70,,213.64,percent of total billed charges,70% of total billed charges,267.05,70,,213.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,184.95,48.48,,147.96,percent of total billed charges,48.48% of total billed charges,343.35,90,,274.68,percent of total billed charges,90% of total billed charges,48.48,343.35,
CMPLX RPR S/A/L ADDL 5 CM/>,36010215,CDM,450,RC,13122,HCPCS,outpatient,,,234.87,140.92,22,399,100,,,fee schedule,100% of asc tier groupings rate,112.74,48,,90.192,percent of total billed charges,48% of total billed charges,117.44,50,,93.952,percent of total billed charges,50% of total billed charges,117.44,50,,93.952,percent of total billed charges,50% of total billed charges,117.44,50,,93.952,percent of total billed charges,50% of total billed charges,117.44,50,,93.952,percent of total billed charges,50% of total billed charges,164.41,70,,131.528,percent of total billed charges,70% of total billed charges,113.86,48.48,,91.088,percent of total billed charges,48.48% of total billed charges,92.15,116.15,,,fee schedule,116.51% of cms physician fee schedule,113.86,48.48,,91.088,percent of total billed charges,48.48% of total billed charges,164.41,70,,131.528,percent of total billed charges,70% of total billed charges,164.41,70,,131.528,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,113.86,48.48,,91.088,percent of total billed charges,48.48% of total billed charges,211.38,90,,169.104,percent of total billed charges,90% of total billed charges,48.48,211.38,
I&D OUTER EAR ABSCESS,36013013,CDM,450,RC,69020,HCPCS,outpatient,,,218.75,131.25,,399,100,,,fee schedule,100% of asc tier groupings rate,105,48,,84,percent of total billed charges,48% of total billed charges,245.57,100,,,fee schedule,100% of bcbs custom fee schedule,245.57,100,,,fee schedule,100% of bcbs custom fee schedule,272.58,111,,,fee schedule,111% of bcbs custom fee schedule,109.38,50,,87.504,percent of total billed charges,50% of total billed charges,153.13,70,,122.504,percent of total billed charges,70% of total billed charges,106.05,48.48,,84.84,percent of total billed charges,48.48% of total billed charges,157.28,116.15,,,fee schedule,116.51% of cms physician fee schedule,106.05,48.48,,84.84,percent of total billed charges,48.48% of total billed charges,153.13,70,,122.504,percent of total billed charges,70% of total billed charges,153.13,70,,122.504,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,106.05,48.48,,84.84,percent of total billed charges,48.48% of total billed charges,196.88,90,,157.504,percent of total billed charges,90% of total billed charges,48.48,196.88,
I&D SKIN ABSCESS COMP,36010001,CDM,450,RC,10061,HCPCS,outpatient,,,554.76,332.86,,399,100,,,fee schedule,100% of asc tier groupings rate,266.28,48,,213.024,percent of total billed charges,48% of total billed charges,623.84,100,,,fee schedule,100% of bcbs custom fee schedule,623.84,100,,,fee schedule,100% of bcbs custom fee schedule,692.46,111,,,fee schedule,111% of bcbs custom fee schedule,277.38,50,,221.904,percent of total billed charges,50% of total billed charges,388.33,70,,310.664,percent of total billed charges,70% of total billed charges,268.95,48.48,,215.16,percent of total billed charges,48.48% of total billed charges,203.37,116.15,,,fee schedule,116.51% of cms physician fee schedule,268.95,48.48,,215.16,percent of total billed charges,48.48% of total billed charges,388.33,70,,310.664,percent of total billed charges,70% of total billed charges,388.33,70,,310.664,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,268.95,48.48,,215.16,percent of total billed charges,48.48% of total billed charges,499.28,90,,399.424,percent of total billed charges,90% of total billed charges,48.48,499.28,
CLTX RDL HEAD SUBLXTJ CHD NURSEMAID ELBW,36010041,CDM,450,RC,24640,HCPCS,outpatient,,,213.44,128.06,,128.06,60,,102.448,percent of total billed charges,60% of total billed charges,102.45,48,,81.96,percent of total billed charges,48% of total billed charges,279.73,100,,,fee schedule,100% of bcbs custom fee schedule,279.73,100,,,fee schedule,100% of bcbs custom fee schedule,310.5,111,,,fee schedule,111% of bcbs custom fee schedule,106.72,50,,85.376,percent of total billed charges,50% of total billed charges,149.41,70,,119.528,percent of total billed charges,70% of total billed charges,103.48,48.48,,82.784,percent of total billed charges,48.48% of total billed charges,88.88,116.15,,,fee schedule,116.51% of cms physician fee schedule,103.48,48.48,,82.784,percent of total billed charges,48.48% of total billed charges,149.41,70,,119.528,percent of total billed charges,70% of total billed charges,149.41,70,,119.528,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,103.48,48.48,,82.784,percent of total billed charges,48.48% of total billed charges,192.1,90,,153.68,percent of total billed charges,90% of total billed charges,48.48,192.1,
REMOVAL FB XTERNAL EYE,36010109,CDM,450,RC,65220,HCPCS,outpatient,,,244,146.40,,146.4,60,,117.12,percent of total billed charges,60% of total billed charges,117.12,48,,93.696,percent of total billed charges,48% of total billed charges,201.3,100,,,fee schedule,100% of bcbs custom fee schedule,201.3,100,,,fee schedule,100% of bcbs custom fee schedule,223.44,111,,,fee schedule,111% of bcbs custom fee schedule,122,50,,97.6,percent of total billed charges,50% of total billed charges,170.8,70,,136.64,percent of total billed charges,70% of total billed charges,118.29,48.48,,94.632,percent of total billed charges,48.48% of total billed charges,46,116.15,,,fee schedule,116.51% of cms physician fee schedule,118.29,48.48,,94.632,percent of total billed charges,48.48% of total billed charges,170.8,70,,136.64,percent of total billed charges,70% of total billed charges,170.8,70,,136.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,118.29,48.48,,94.632,percent of total billed charges,48.48% of total billed charges,219.6,90,,175.68,percent of total billed charges,90% of total billed charges,48.48,219.6,
REPAIR INTERMEDIATE S/A/T/E 7.6-12.5 CM,36010020,CDM,450,RC,12034,HCPCS,outpatient,,,404.65,242.79,,535,100,,,fee schedule,100% of asc tier groupings rate,194.23,48,,155.384,percent of total billed charges,48% of total billed charges,616.4,100,,,fee schedule,100% of bcbs custom fee schedule,616.4,100,,,fee schedule,100% of bcbs custom fee schedule,684.2,111,,,fee schedule,111% of bcbs custom fee schedule,202.33,50,,161.864,percent of total billed charges,50% of total billed charges,283.26,70,,226.608,percent of total billed charges,70% of total billed charges,196.17,48.48,,156.936,percent of total billed charges,48.48% of total billed charges,226.68,116.15,,,fee schedule,116.51% of cms physician fee schedule,196.17,48.48,,156.936,percent of total billed charges,48.48% of total billed charges,283.26,70,,226.608,percent of total billed charges,70% of total billed charges,283.26,70,,226.608,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,196.17,48.48,,156.936,percent of total billed charges,48.48% of total billed charges,364.19,90,,291.352,percent of total billed charges,90% of total billed charges,48.48,364.19,
PLACEMENT OF NEEDLE INTRAOSSEOUS INFUSE,36011054,CDM,260,RC,36680,HCPCS,outpatient,,,183.8,110.28,,399,100,,,fee schedule,100% of asc tier groupings rate,88.22,48,,70.576,percent of total billed charges,48% of total billed charges,152.16,100,,,fee schedule,100% of bcbs custom fee schedule,152.16,100,,,fee schedule,100% of bcbs custom fee schedule,168.9,111,,,fee schedule,111% of bcbs custom fee schedule,91.9,50,,73.52,percent of total billed charges,50% of total billed charges,128.66,70,,102.928,percent of total billed charges,70% of total billed charges,89.11,48.48,,71.288,percent of total billed charges,48.48% of total billed charges,67.97,116.15,,,fee schedule,116.51% of cms physician fee schedule,89.11,48.48,,71.288,percent of total billed charges,48.48% of total billed charges,128.66,70,,102.928,percent of total billed charges,70% of total billed charges,128.66,70,,102.928,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,89.11,48.48,,71.288,percent of total billed charges,48.48% of total billed charges,165.42,90,,132.336,percent of total billed charges,90% of total billed charges,48.48,165.42,
REMOVAL FB,36010005,CDM,450,RC,10120,HCPCS,outpatient,,,368.75,221.25,,399,100,,,fee schedule,100% of asc tier groupings rate,177,48,,141.6,percent of total billed charges,48% of total billed charges,616.4,100,,,fee schedule,100% of bcbs custom fee schedule,616.4,100,,,fee schedule,100% of bcbs custom fee schedule,684.2,111,,,fee schedule,111% of bcbs custom fee schedule,184.38,50,,147.504,percent of total billed charges,50% of total billed charges,258.13,70,,206.504,percent of total billed charges,70% of total billed charges,178.77,48.48,,143.016,percent of total billed charges,48.48% of total billed charges,115.44,116.15,,,fee schedule,116.51% of cms physician fee schedule,178.77,48.48,,143.016,percent of total billed charges,48.48% of total billed charges,258.13,70,,206.504,percent of total billed charges,70% of total billed charges,258.13,70,,206.504,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,178.77,48.48,,143.016,percent of total billed charges,48.48% of total billed charges,331.88,90,,265.504,percent of total billed charges,90% of total billed charges,48.48,331.88,
RESET DISLOCATED JAW,36010211,CDM,450,RC,21480,HCPCS,outpatient,,,177.5,106.50,,399,100,,,fee schedule,100% of asc tier groupings rate,85.2,48,,68.16,percent of total billed charges,48% of total billed charges,338.1,100,,,fee schedule,100% of bcbs custom fee schedule,338.1,100,,,fee schedule,100% of bcbs custom fee schedule,375.29,111,,,fee schedule,111% of bcbs custom fee schedule,88.75,50,,71,percent of total billed charges,50% of total billed charges,124.25,70,,99.4,percent of total billed charges,70% of total billed charges,86.05,48.48,,68.84,percent of total billed charges,48.48% of total billed charges,35.66,116.15,,,fee schedule,116.51% of cms physician fee schedule,86.05,48.48,,68.84,percent of total billed charges,48.48% of total billed charges,124.25,70,,99.4,percent of total billed charges,70% of total billed charges,124.25,70,,99.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,86.05,48.48,,68.84,percent of total billed charges,48.48% of total billed charges,159.75,90,,127.8,percent of total billed charges,90% of total billed charges,48.48,159.75,
DRAGE PILONDAL CYST CMP,,,450,RC,10081,HCPCS,outpatient,,,442.5,265.50,,399,100,,,fee schedule,100% of asc tier groupings rate,212.4,48,,169.92,percent of total billed charges,48% of total billed charges,221.25,50,,177,percent of total billed charges,50% of total billed charges,221.25,50,,177,percent of total billed charges,50% of total billed charges,221.25,50,,177,percent of total billed charges,50% of total billed charges,221.25,50,,177,percent of total billed charges,50% of total billed charges,309.75,70,,247.8,percent of total billed charges,70% of total billed charges,214.52,48.48,,171.616,percent of total billed charges,48.48% of total billed charges,191.28,116.15,,,fee schedule,116.51% of cms physician fee schedule,214.52,48.48,,171.616,percent of total billed charges,48.48% of total billed charges,309.75,70,,247.8,percent of total billed charges,70% of total billed charges,309.75,70,,247.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,214.52,48.48,,171.616,percent of total billed charges,48.48% of total billed charges,398.25,90,,318.6,percent of total billed charges,90% of total billed charges,48.48,398.25,
Tracheostomy Tube Collar (Tie),,,270,RC,A7526,HCPCS,outpatient,,,11.22,6.73,,6.73,60,,5.384,percent of total billed charges,60% of total billed charges,5.39,48,,4.312,percent of total billed charges,48% of total billed charges,5.61,50,,4.488,percent of total billed charges,50% of total billed charges,5.61,50,,4.488,percent of total billed charges,50% of total billed charges,5.61,50,,4.488,percent of total billed charges,50% of total billed charges,5.61,50,,4.488,percent of total billed charges,50% of total billed charges,7.85,70,,6.28,percent of total billed charges,70% of total billed charges,5.44,48.48,,4.352,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,5.44,48.48,,4.352,percent of total billed charges,48.48% of total billed charges,7.85,70,,6.28,percent of total billed charges,70% of total billed charges,7.85,70,,6.28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,5.44,48.48,,4.352,percent of total billed charges,48.48% of total billed charges,10.1,90,,8.08,percent of total billed charges,90% of total billed charges,5.44,90,
BEHAV CHNG SMOKING 3-10,32009065,CDM,942,RC,99406,HCPCS,outpatient,,,40,24.00,,24,60,,19.2,percent of total billed charges,60% of total billed charges,19.2,48,,15.36,percent of total billed charges,48% of total billed charges,23.1,100,,,fee schedule,100% of bcbs custom fee schedule,23.1,100,,,fee schedule,100% of bcbs custom fee schedule,25.64,111,,,fee schedule,111% of bcbs custom fee schedule,20,50,,16,percent of total billed charges,50% of total billed charges,28,70,,22.4,percent of total billed charges,70% of total billed charges,19.39,48.48,,15.512,percent of total billed charges,48.48% of total billed charges,13.21,116.15,,,fee schedule,116.51% of cms physician fee schedule,19.39,48.48,,15.512,percent of total billed charges,48.48% of total billed charges,28,70,,22.4,percent of total billed charges,70% of total billed charges,28,70,,22.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,19.39,48.48,,15.512,percent of total billed charges,48.48% of total billed charges,36,90,,28.8,percent of total billed charges,90% of total billed charges,19.39,90,
PHYSICIAN LEVEL I .,36000041,CDM,981,RC,99281,HCPCS,outpatient,,,101.25,60.75,,,,,,other,not separately reimbusable,11.21,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,20.95,100,,,fee schedule,100% of cigna custom fee schedule,12.33,110,,,fee schedule,110% of cms physician fee schedule,11.32,101,,,fee schedule,101% of cms physician fee schedule ,11.32,116.15,,,fee schedule,116.51% of cms physician fee schedule,11.32,101,,,fee schedule,101% of cms physician fee schedule,21.3,110,,,fee schedule,110% of humana physician fee schedule,12.33,110,,,fee schedule,110% of humana physician fee schedule,16.82,150,,,fee schedule,100% of cms fee schedule,11.21,100,,,fee schedule,100% of cms physician fee schedule,16.82,150,,,fee schedule,150% of cms physician fee schedule,11.21,150,
PHYSICIAN LEVEL II,36009002,CDM,981,RC,99282,HCPCS,outpatient,,,118.75,71.25,,,,,,other,not separately reimbusable,40.88,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,40.88,100,,,fee schedule,100% of cigna custom fee schedule,44.97,110,,,fee schedule,110% of cms physician fee schedule,41.29,101,,,fee schedule,101% of cms physician fee schedule ,41.29,116.15,,,fee schedule,116.51% of cms physician fee schedule,41.29,101,,,fee schedule,101% of cms physician fee schedule,77.67,110,,,fee schedule,110% of humana physician fee schedule,44.97,110,,,fee schedule,110% of humana physician fee schedule,61.32,150,,,fee schedule,100% of cms fee schedule,40.88,100,,,fee schedule,100% of cms physician fee schedule,61.32,150,,,fee schedule,150% of cms physician fee schedule,40.88,150,
PHYSICIAN LEVEL III,36009003,CDM,981,RC,99283,HCPCS,outpatient,,,137.5,82.50,,,,,,other,not separately reimbusable,69.64,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,61.25,100,,,fee schedule,100% of cigna custom fee schedule,76.6,110,,,fee schedule,110% of cms physician fee schedule,70.34,101,,,fee schedule,101% of cms physician fee schedule ,70.34,116.15,,,fee schedule,116.51% of cms physician fee schedule,70.34,101,,,fee schedule,101% of cms physician fee schedule,132.32,110,,,fee schedule,110% of humana physician fee schedule,76.6,110,,,fee schedule,110% of humana physician fee schedule,104.46,150,,,fee schedule,100% of cms fee schedule,69.64,100,,,fee schedule,100% of cms physician fee schedule,104.46,150,,,fee schedule,150% of cms physician fee schedule,69.64,150,
PHY TRT ANKLE DISLOCT,36011033,CDM,981,RC,27840,HCPCS,outpatient,,,475.5,285.30,AQ,,,,,other,not separately reimbusable,378.26,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,676.06,100,,,fee schedule,100% of cigna custom fee schedule,416.09,110,,,fee schedule,110% of cms physician fee schedule,382.04,101,,,fee schedule,101% of cms physician fee schedule ,382.04,116.15,,,fee schedule,116.51% of cms physician fee schedule,382.04,101,,,fee schedule,101% of cms physician fee schedule,718.69,110,,,fee schedule,110% of humana physician fee schedule,416.09,110,,,fee schedule,110% of humana physician fee schedule,567.39,150,,,fee schedule,100% of cms fee schedule,378.26,100,,,fee schedule,100% of cms physician fee schedule,567.39,150,,,fee schedule,150% of cms physician fee schedule,100,567.39,
PHYSICIAN LEVEL IV,36009004,CDM,981,RC,99284,HCPCS,outpatient,,,246.25,147.75,,,,,,other,not separately reimbusable,118.58,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,116.3,100,,,fee schedule,100% of cigna custom fee schedule,130.44,110,,,fee schedule,110% of cms physician fee schedule,119.77,101,,,fee schedule,101% of cms physician fee schedule ,119.77,116.15,,,fee schedule,116.51% of cms physician fee schedule,119.77,101,,,fee schedule,101% of cms physician fee schedule,225.3,110,,,fee schedule,110% of humana physician fee schedule,130.44,110,,,fee schedule,110% of humana physician fee schedule,177.87,150,,,fee schedule,100% of cms fee schedule,118.58,100,,,fee schedule,100% of cms physician fee schedule,177.87,150,,,fee schedule,150% of cms physician fee schedule,100,177.87,
DRAINAGE PILONIDAL CYST,,,981,RC,10081,HCPCS,outpatient,,,381.25,228.75,AQ,,,,,other,not separately reimbusable,164.68,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,304.96,100,,,fee schedule,100% of cigna custom fee schedule,181.15,110,,,fee schedule,110% of cms physician fee schedule,166.33,101,,,fee schedule,101% of cms physician fee schedule ,166.33,116.15,,,fee schedule,116.51% of cms physician fee schedule,166.33,101,,,fee schedule,101% of cms physician fee schedule,312.89,110,,,fee schedule,110% of humana physician fee schedule,181.15,110,,,fee schedule,110% of humana physician fee schedule,247.02,150,,,fee schedule,100% of cms fee schedule,164.68,100,,,fee schedule,100% of cms physician fee schedule,247.02,150,,,fee schedule,150% of cms physician fee schedule,100,247.02,
PHYSICIAN LEVEL V,36009005,CDM,981,RC,99285,HCPCS,outpatient,,,517.5,310.50,,,,,,other,not separately reimbusable,171.88,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,171.84,100,,,fee schedule,100% of cigna custom fee schedule,189.07,110,,,fee schedule,110% of cms physician fee schedule,173.6,101,,,fee schedule,101% of cms physician fee schedule ,173.6,116.15,,,fee schedule,116.51% of cms physician fee schedule,173.6,101,,,fee schedule,101% of cms physician fee schedule,326.57,110,,,fee schedule,110% of humana physician fee schedule,189.07,110,,,fee schedule,110% of humana physician fee schedule,257.82,150,,,fee schedule,100% of cms fee schedule,171.88,100,,,fee schedule,100% of cms physician fee schedule,257.82,150,,,fee schedule,150% of cms physician fee schedule,100,257.82,
PF Treat Knuckle Dislocation,36010057,CDM,981,RC,26700,HCPCS,outpatient,,,404,242.40,,,,,,other,not separately reimbusable,308.35,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,555.04,100,,,fee schedule,100% of cigna custom fee schedule,339.19,110,,,fee schedule,110% of cms physician fee schedule,311.43,101,,,fee schedule,101% of cms physician fee schedule ,311.43,116.15,,,fee schedule,116.51% of cms physician fee schedule,311.43,101,,,fee schedule,101% of cms physician fee schedule,585.87,110,,,fee schedule,110% of humana physician fee schedule,339.19,110,,,fee schedule,110% of humana physician fee schedule,462.53,150,,,fee schedule,100% of cms fee schedule,308.35,100,,,fee schedule,100% of cms physician fee schedule,462.53,150,,,fee schedule,150% of cms physician fee schedule,100,462.53,
I & D OF ABS SIMPL/SINGLE,36010135,CDM,981,RC,10060,HCPCS,outpatient,,,200.38,120.23,AQ,,,,,other,not separately reimbusable,100.09,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,171.79,100,,,fee schedule,100% of cigna custom fee schedule,110.1,110,,,fee schedule,110% of cms physician fee schedule,101.09,101,,,fee schedule,101% of cms physician fee schedule ,101.09,116.15,,,fee schedule,116.51% of cms physician fee schedule,101.09,101,,,fee schedule,101% of cms physician fee schedule,190.17,110,,,fee schedule,110% of humana physician fee schedule,110.1,110,,,fee schedule,110% of humana physician fee schedule,150.14,150,,,fee schedule,100% of cms fee schedule,100.09,100,,,fee schedule,100% of cms physician fee schedule,150.14,150,,,fee schedule,150% of cms physician fee schedule,100,150.14,
I & D CYST COMP/MULTIPLE,36010001,CDM,981,RC,10061,HCPCS,outpatient,,,511.11,306.67,,,,,,other,not separately reimbusable,175.09,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,319.7,100,,,fee schedule,100% of cigna custom fee schedule,192.6,110,,,fee schedule,110% of cms physician fee schedule,176.84,101,,,fee schedule,101% of cms physician fee schedule ,176.84,116.15,,,fee schedule,116.51% of cms physician fee schedule,176.84,101,,,fee schedule,101% of cms physician fee schedule,332.67,110,,,fee schedule,110% of humana physician fee schedule,192.6,110,,,fee schedule,110% of humana physician fee schedule,262.64,150,,,fee schedule,100% of cms fee schedule,175.09,100,,,fee schedule,100% of cms physician fee schedule,262.64,150,,,fee schedule,150% of cms physician fee schedule,100,262.64,
I & D PILONDAL CYST SMPLE,36010189,CDM,981,RC,10080,HCPCS,outpatient,,,188.75,113.25,AQ,,,,,other,not separately reimbusable,99.54,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,182.04,100,,,fee schedule,100% of cigna custom fee schedule,109.49,110,,,fee schedule,110% of cms physician fee schedule,100.54,101,,,fee schedule,101% of cms physician fee schedule ,100.54,116.15,,,fee schedule,116.51% of cms physician fee schedule,100.54,101,,,fee schedule,101% of cms physician fee schedule,189.13,110,,,fee schedule,110% of humana physician fee schedule,109.49,110,,,fee schedule,110% of humana physician fee schedule,149.31,150,,,fee schedule,100% of cms fee schedule,99.54,100,,,fee schedule,100% of cms physician fee schedule,149.31,150,,,fee schedule,150% of cms physician fee schedule,99.54,150,
INC & REM FB SQ TISS;SMPL,36010005,CDM,981,RC,10120,HCPCS,outpatient,,,315,189.00,AQ,,,,,other,not separately reimbusable,99.39,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,181.79,100,,,fee schedule,100% of cigna custom fee schedule,109.33,110,,,fee schedule,110% of cms physician fee schedule,100.38,101,,,fee schedule,101% of cms physician fee schedule ,100.38,116.15,,,fee schedule,116.51% of cms physician fee schedule,100.38,101,,,fee schedule,101% of cms physician fee schedule,188.84,110,,,fee schedule,110% of humana physician fee schedule,109.33,110,,,fee schedule,110% of humana physician fee schedule,149.09,150,,,fee schedule,100% of cms fee schedule,99.39,100,,,fee schedule,100% of cms physician fee schedule,149.09,150,,,fee schedule,150% of cms physician fee schedule,99.39,150,
I&D OF HEMATOMA,36010194,CDM,981,RC,10140,HCPCS,outpatient,,,245.54,147.32,AQ,,,,,other,not separately reimbusable,112.49,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,210.44,100,,,fee schedule,100% of cigna custom fee schedule,123.74,110,,,fee schedule,110% of cms physician fee schedule,113.61,101,,,fee schedule,101% of cms physician fee schedule ,113.61,116.15,,,fee schedule,116.51% of cms physician fee schedule,113.61,101,,,fee schedule,101% of cms physician fee schedule,213.73,110,,,fee schedule,110% of humana physician fee schedule,123.74,110,,,fee schedule,110% of humana physician fee schedule,168.74,150,,,fee schedule,100% of cms fee schedule,112.49,100,,,fee schedule,100% of cms physician fee schedule,168.74,150,,,fee schedule,150% of cms physician fee schedule,100,168.74,
PUNCT ASP CYST/ABSC,36010150,CDM,981,RC,10160,HCPCS,outpatient,,,188.75,113.25,AQ,,,,,other,not separately reimbusable,91.44,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,170.32,100,,,fee schedule,100% of cigna custom fee schedule,100.58,110,,,fee schedule,110% of cms physician fee schedule,92.35,101,,,fee schedule,101% of cms physician fee schedule ,92.35,116.15,,,fee schedule,116.51% of cms physician fee schedule,92.35,101,,,fee schedule,101% of cms physician fee schedule,173.74,110,,,fee schedule,110% of humana physician fee schedule,100.58,110,,,fee schedule,110% of humana physician fee schedule,137.16,150,,,fee schedule,100% of cms fee schedule,91.44,100,,,fee schedule,100% of cms physician fee schedule,137.16,150,,,fee schedule,150% of cms physician fee schedule,91.44,150,
PHY FEE DEBRIDE INFECTED SKIN ADD ON,,,981,RC,11001,HCPCS,outpatient,,,185.56,111.34,,,,,,other,not separately reimbusable,14.33,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,17.09,100,,,fee schedule,100% of cigna custom fee schedule,15.76,110,,,fee schedule,110% of cms physician fee schedule,14.47,101,,,fee schedule,101% of cms physician fee schedule ,14.47,116.15,,,fee schedule,116.51% of cms physician fee schedule,14.47,101,,,fee schedule,101% of cms physician fee schedule,27.23,110,,,fee schedule,110% of humana physician fee schedule,15.76,110,,,fee schedule,110% of humana physician fee schedule,21.5,150,,,fee schedule,100% of cms fee schedule,14.33,100,,,fee schedule,100% of cms physician fee schedule,21.5,150,,,fee schedule,150% of cms physician fee schedule,14.33,150,
DEBRIDE INFEC LES 10% BS,36010006,CDM,981,RC,11000,HCPCS,outpatient,,,1213.99,728.39,AQ,,,,,other,not separately reimbusable,26.83,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,34.05,100,,,fee schedule,100% of cigna custom fee schedule,29.51,110,,,fee schedule,110% of cms physician fee schedule,27.1,101,,,fee schedule,101% of cms physician fee schedule ,27.1,116.15,,,fee schedule,116.51% of cms physician fee schedule,27.1,101,,,fee schedule,101% of cms physician fee schedule,50.98,110,,,fee schedule,110% of humana physician fee schedule,29.51,110,,,fee schedule,110% of humana physician fee schedule,40.25,150,,,fee schedule,100% of cms fee schedule,26.83,100,,,fee schedule,100% of cms physician fee schedule,40.25,150,,,fee schedule,150% of cms physician fee schedule,26.83,150,
RVL DEVITAL TIS 20 CM,36000015,CDM,981,RC,97597,HCPCS,outpatient,,,47.7,28.62,,,,,,other,not separately reimbusable,34.33,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,12.82,100,,,fee schedule,100% of cigna custom fee schedule,65.23,110,,,fee schedule,110% of cms physician fee schedule,34.67,101,,,fee schedule,101% of cms physician fee schedule ,34.67,116.15,,,fee schedule,116.51% of cms physician fee schedule,34.67,101,,,fee schedule,101% of cms physician fee schedule,27.46,80,,,fee schedule,80% of humana physician fee schedule,27.46,110,,,fee schedule,110% of humana physician fee schedule,51.5,150,,,fee schedule,100% of cms fee schedule,34.33,100,,,fee schedule,100% of cms physician fee schedule,51.5,150,,,fee schedule,150% of cms physician fee schedule,34.33,150,
DEBRD WD SURFACE <20 SQCM,43601432,CDM,981,RC,97598,HCPCS,outpatient,,,22.42,13.45,GP,,,,,other,not separately reimbusable,22.42,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,6.03,100,,,fee schedule,100% of cigna custom fee schedule,42.6,110,,,fee schedule,110% of cms physician fee schedule,22.64,101,,,fee schedule,101% of cms physician fee schedule ,22.64,116.15,,,fee schedule,116.51% of cms physician fee schedule,22.64,101,,,fee schedule,101% of cms physician fee schedule,17.94,80,,,fee schedule,80% of humana physician fee schedule,17.94,110,,,fee schedule,110% of humana physician fee schedule,33.63,150,,,fee schedule,100% of cms fee schedule,22.42,100,,,fee schedule,100% of cms physician fee schedule,33.63,150,,,fee schedule,150% of cms physician fee schedule,22.42,150,
WC PHY DEB SUBQ TISSUE ADD-ON,44500017,CDM,981,RC,11045,HCPCS,outpatient,,,52.7,31.62,,,,,,other,not separately reimbusable,24.64,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,31.23,100,,,fee schedule,100% of cigna custom fee schedule,27.1,110,,,fee schedule,110% of cms physician fee schedule,24.89,101,,,fee schedule,101% of cms physician fee schedule ,24.89,116.15,,,fee schedule,116.51% of cms physician fee schedule,24.89,101,,,fee schedule,101% of cms physician fee schedule,46.82,80,,,fee schedule,80% of humana physician fee schedule,27.1,110,,,fee schedule,110% of humana physician fee schedule,36.96,150,,,fee schedule,100% of cms fee schedule,24.64,100,,,fee schedule,100% of cms physician fee schedule,36.96,150,,,fee schedule,150% of cms physician fee schedule,24.64,150,
DEBRIDE SKIN/SQ TISS&MUSC,44500018,CDM,981,RC,11043,HCPCS,outpatient,,,331.52,198.91,,,,,,other,not separately reimbusable,148.26,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,184.83,100,,,fee schedule,100% of cigna custom fee schedule,163.09,110,,,fee schedule,110% of cms physician fee schedule,149.74,101,,,fee schedule,101% of cms physician fee schedule ,149.74,116.15,,,fee schedule,116.51% of cms physician fee schedule,149.74,101,,,fee schedule,101% of cms physician fee schedule,281.69,110,,,fee schedule,110% of humana physician fee schedule,163.09,110,,,fee schedule,110% of humana physician fee schedule,222.39,150,,,fee schedule,100% of cms fee schedule,148.26,100,,,fee schedule,100% of cms physician fee schedule,222.39,150,,,fee schedule,150% of cms physician fee schedule,100,222.39,
DEB MUSC/FASCIA ADD-ON,44500019,CDM,981,RC,11046,HCPCS,outpatient,,,1289.01,773.41,,,,,,other,not separately reimbusable,53.47,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,67.6,100,,,fee schedule,100% of cigna custom fee schedule,58.82,110,,,fee schedule,110% of cms physician fee schedule,54,101,,,fee schedule,101% of cms physician fee schedule ,54,116.15,,,fee schedule,116.51% of cms physician fee schedule,54,101,,,fee schedule,101% of cms physician fee schedule,101.59,110,,,fee schedule,110% of humana physician fee schedule,58.82,110,,,fee schedule,110% of humana physician fee schedule,80.21,150,,,fee schedule,100% of cms fee schedule,53.47,100,,,fee schedule,100% of cms physician fee schedule,80.21,150,,,fee schedule,150% of cms physician fee schedule,53.47,150,
PAR/CUT B9 LES; SINGLE,43600315,CDM,981,RC,11055,HCPCS,outpatient,,,107.5,64.50,AQ,,,,,other,not separately reimbusable,15.12,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,19.06,100,,,fee schedule,100% of cigna custom fee schedule,16.63,110,,,fee schedule,110% of cms physician fee schedule,15.27,101,,,fee schedule,101% of cms physician fee schedule ,15.27,116.15,,,fee schedule,116.51% of cms physician fee schedule,15.27,101,,,fee schedule,101% of cms physician fee schedule,28.73,110,,,fee schedule,110% of humana physician fee schedule,16.63,110,,,fee schedule,110% of humana physician fee schedule,22.68,150,,,fee schedule,100% of cms fee schedule,15.12,100,,,fee schedule,100% of cms physician fee schedule,22.68,150,,,fee schedule,150% of cms physician fee schedule,15.12,150,
DEB BONE 20 SQ CM/<,44500020,CDM,981,RC,11044,HCPCS,outpatient,,,494.76,296.86,,,,,,other,not separately reimbusable,218.76,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,275.86,100,,,fee schedule,100% of cigna custom fee schedule,240.64,110,,,fee schedule,110% of cms physician fee schedule,220.95,101,,,fee schedule,101% of cms physician fee schedule ,220.95,116.15,,,fee schedule,116.51% of cms physician fee schedule,220.95,101,,,fee schedule,101% of cms physician fee schedule,415.64,110,,,fee schedule,110% of humana physician fee schedule,240.64,110,,,fee schedule,110% of humana physician fee schedule,328.14,150,,,fee schedule,100% of cms fee schedule,218.76,100,,,fee schedule,100% of cms physician fee schedule,328.14,150,,,fee schedule,150% of cms physician fee schedule,100,328.14,
BX SKIN SQ TISS/MM;SINGLE,43601383,CDM,981,RC,11104,HCPCS,outpatient,,,580,348.00,,,,,,other,not separately reimbusable,44.85,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,58.65,100,,,fee schedule,100% of cigna custom fee schedule,49.34,110,,,fee schedule,110% of cms physician fee schedule,45.3,101,,,fee schedule,101% of cms physician fee schedule ,45.3,116.15,,,fee schedule,116.51% of cms physician fee schedule,45.3,101,,,fee schedule,101% of cms physician fee schedule,85.22,110,,,fee schedule,110% of humana physician fee schedule,49.34,110,,,fee schedule,110% of humana physician fee schedule,67.28,150,,,fee schedule,100% of cms fee schedule,44.85,100,,,fee schedule,100% of cms physician fee schedule,67.28,150,,,fee schedule,150% of cms physician fee schedule,44.85,150,
DEB BONE ADD ON,44500021,CDM,981,RC,11047,HCPCS,outpatient,,,204.22,122.53,,,,,,other,not separately reimbusable,94.53,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,120.3,100,,,fee schedule,100% of cigna custom fee schedule,103.98,110,,,fee schedule,110% of cms physician fee schedule,95.48,101,,,fee schedule,101% of cms physician fee schedule ,95.48,116.15,,,fee schedule,116.51% of cms physician fee schedule,95.48,101,,,fee schedule,101% of cms physician fee schedule,179.61,110,,,fee schedule,110% of humana physician fee schedule,103.98,110,,,fee schedule,110% of humana physician fee schedule,141.8,150,,,fee schedule,100% of cms fee schedule,94.53,100,,,fee schedule,100% of cms physician fee schedule,141.8,150,,,fee schedule,150% of cms physician fee schedule,94.53,150,
BX SKIN SQ TISS/MM EA ADD,43601384,CDM,981,RC,11105,HCPCS,outpatient,,,107.5,64.50,,,,,,other,not separately reimbusable,24.55,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,31.98,100,,,fee schedule,100% of cigna custom fee schedule,27.01,110,,,fee schedule,110% of cms physician fee schedule,24.8,101,,,fee schedule,101% of cms physician fee schedule ,24.8,116.15,,,fee schedule,116.51% of cms physician fee schedule,24.8,101,,,fee schedule,101% of cms physician fee schedule,46.65,110,,,fee schedule,110% of humana physician fee schedule,27.01,110,,,fee schedule,110% of humana physician fee schedule,36.83,150,,,fee schedule,100% of cms fee schedule,24.55,100,,,fee schedule,100% of cms physician fee schedule,36.83,150,,,fee schedule,150% of cms physician fee schedule,24.55,150,
REMOVAL SKIN TAG+^ LES,36010161,CDM,981,RC,11200,HCPCS,outpatient,,,107.5,64.50,,,,,,other,not separately reimbusable,71.54,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,83.93,100,,,fee schedule,100% of cigna custom fee schedule,78.69,110,,,fee schedule,110% of cms physician fee schedule,72.26,101,,,fee schedule,101% of cms physician fee schedule ,72.26,116.15,,,fee schedule,116.51% of cms physician fee schedule,72.26,101,,,fee schedule,101% of cms physician fee schedule,135.93,110,,,fee schedule,110% of humana physician fee schedule,78.69,110,,,fee schedule,110% of humana physician fee schedule,107.31,150,,,fee schedule,100% of cms fee schedule,71.54,100,,,fee schedule,100% of cms physician fee schedule,107.31,150,,,fee schedule,150% of cms physician fee schedule,71.54,150,
REMOVL SKIN TAG EA ADD 10,43600288,CDM,981,RC,11201,HCPCS,outpatient,,,107.5,64.50,,,,,,other,not separately reimbusable,15.46,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,19.78,100,,,fee schedule,100% of cigna custom fee schedule,17.01,110,,,fee schedule,110% of cms physician fee schedule,15.61,101,,,fee schedule,101% of cms physician fee schedule ,15.61,116.15,,,fee schedule,116.51% of cms physician fee schedule,15.61,101,,,fee schedule,101% of cms physician fee schedule,29.37,110,,,fee schedule,110% of humana physician fee schedule,17.01,110,,,fee schedule,110% of humana physician fee schedule,23.19,150,,,fee schedule,100% of cms fee schedule,15.46,100,,,fee schedule,100% of cms physician fee schedule,23.19,150,,,fee schedule,150% of cms physician fee schedule,15.46,150,
"BX SKIN INCISIONAL, SINGLE LESION",43601385,CDM,761,RC,11106,HCPCS,outpatient,,,265.79,159.47,,399,100,,,fee schedule,100% of asc tier groupings rate,127.58,48,,102.064,percent of total billed charges,48% of total billed charges,858.34,100,,,fee schedule,100% of bcbs custom fee schedule,858.34,100,,,fee schedule,100% of bcbs custom fee schedule,952.76,111,,,fee schedule,111% of bcbs custom fee schedule,132.9,50,,106.32,percent of total billed charges,50% of total billed charges,186.05,70,,148.84,percent of total billed charges,70% of total billed charges,128.85,48.48,,103.08,percent of total billed charges,48.48% of total billed charges,63.08,116.15,,,fee schedule,116.51% of cms physician fee schedule,128.85,48.48,,103.08,percent of total billed charges,48.48% of total billed charges,186.05,70,,148.84,percent of total billed charges,70% of total billed charges,186.05,70,,148.84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,128.85,48.48,,103.08,percent of total billed charges,48.48% of total billed charges,239.21,90,,191.368,percent of total billed charges,90% of total billed charges,48.48,239.21,
"BX SKIN INCISIONAL, SINGLE LESION",43601385,CDM,981,RC,11106,HCPCS,outpatient,,,177.19,106.31,,,,,,other,not separately reimbusable,54.31,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,71.45,100,,,fee schedule,100% of cigna custom fee schedule,59.74,110,,,fee schedule,110% of cms physician fee schedule,54.85,101,,,fee schedule,101% of cms physician fee schedule ,54.85,116.15,,,fee schedule,116.51% of cms physician fee schedule,54.85,101,,,fee schedule,101% of cms physician fee schedule,103.19,110,,,fee schedule,110% of humana physician fee schedule,59.74,110,,,fee schedule,110% of humana physician fee schedule,81.47,150,,,fee schedule,100% of cms fee schedule,54.31,100,,,fee schedule,100% of cms physician fee schedule,81.47,150,,,fee schedule,150% of cms physician fee schedule,54.31,150,
EXC B9 LES TR-EXT 0.5<CM,43600197,CDM,981,RC,11400,HCPCS,outpatient,,,505,303.00,,,,,,other,not separately reimbusable,79.14,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,92.03,100,,,fee schedule,100% of cigna custom fee schedule,87.05,110,,,fee schedule,110% of cms physician fee schedule,79.93,101,,,fee schedule,101% of cms physician fee schedule ,79.93,116.15,,,fee schedule,116.51% of cms physician fee schedule,79.93,101,,,fee schedule,101% of cms physician fee schedule,150.37,110,,,fee schedule,110% of humana physician fee schedule,87.05,110,,,fee schedule,110% of humana physician fee schedule,118.71,150,,,fee schedule,100% of cms fee schedule,79.14,100,,,fee schedule,100% of cms physician fee schedule,118.71,150,,,fee schedule,150% of cms physician fee schedule,79.14,150,
EXC B9 LES T/N/L 0.6-1.0,43600198,CDM,981,RC,11401,HCPCS,outpatient,,,505,303.00,,,,,,other,not separately reimbusable,99.73,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,119.58,100,,,fee schedule,100% of cigna custom fee schedule,109.7,110,,,fee schedule,110% of cms physician fee schedule,100.73,101,,,fee schedule,101% of cms physician fee schedule ,100.73,116.15,,,fee schedule,116.51% of cms physician fee schedule,100.73,101,,,fee schedule,101% of cms physician fee schedule,189.49,110,,,fee schedule,110% of humana physician fee schedule,109.7,110,,,fee schedule,110% of humana physician fee schedule,149.6,150,,,fee schedule,100% of cms fee schedule,99.73,100,,,fee schedule,100% of cms physician fee schedule,149.6,150,,,fee schedule,150% of cms physician fee schedule,99.73,150,
EXC B9 LES T/A/L 1.1-2.0,43600199,CDM,981,RC,11402,HCPCS,outpatient,,,505,303.00,,,,,,other,not separately reimbusable,109.44,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,131.71,100,,,fee schedule,100% of cigna custom fee schedule,120.38,110,,,fee schedule,110% of cms physician fee schedule,110.53,101,,,fee schedule,101% of cms physician fee schedule ,110.53,116.15,,,fee schedule,116.51% of cms physician fee schedule,110.53,101,,,fee schedule,101% of cms physician fee schedule,207.94,110,,,fee schedule,110% of humana physician fee schedule,120.38,110,,,fee schedule,110% of humana physician fee schedule,164.16,150,,,fee schedule,100% of cms fee schedule,109.44,100,,,fee schedule,100% of cms physician fee schedule,164.16,150,,,fee schedule,150% of cms physician fee schedule,100,164.16,
EXC B9 LES S/N/H/F/G .6-1,43600201,CDM,981,RC,11421,HCPCS,outpatient,,,656.25,393.75,,,,,,other,not separately reimbusable,103.52,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,127.31,100,,,fee schedule,100% of cigna custom fee schedule,113.87,110,,,fee schedule,110% of cms physician fee schedule,104.56,101,,,fee schedule,101% of cms physician fee schedule ,104.56,116.15,,,fee schedule,116.51% of cms physician fee schedule,104.56,101,,,fee schedule,101% of cms physician fee schedule,196.69,110,,,fee schedule,110% of humana physician fee schedule,113.87,110,,,fee schedule,110% of humana physician fee schedule,155.28,150,,,fee schedule,100% of cms fee schedule,103.52,100,,,fee schedule,100% of cms physician fee schedule,155.28,150,,,fee schedule,150% of cms physician fee schedule,100,155.28,
EXC B9 LES S/N/H/F/G1.1-2,43600202,CDM,981,RC,11422,HCPCS,outpatient,,,875,525.00,,,,,,other,not separately reimbusable,128.36,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,156.16,100,,,fee schedule,100% of cigna custom fee schedule,141.2,110,,,fee schedule,110% of cms physician fee schedule,129.64,101,,,fee schedule,101% of cms physician fee schedule ,129.64,116.15,,,fee schedule,116.51% of cms physician fee schedule,129.64,101,,,fee schedule,101% of cms physician fee schedule,243.88,110,,,fee schedule,110% of humana physician fee schedule,141.2,110,,,fee schedule,110% of humana physician fee schedule,192.54,150,,,fee schedule,100% of cms fee schedule,128.36,100,,,fee schedule,100% of cms physician fee schedule,192.54,150,,,fee schedule,150% of cms physician fee schedule,100,192.54,
EXC B9 LES FCE-MM 1.1-2CM,43600205,CDM,981,RC,11442,HCPCS,outpatient,,,875,525.00,,,,,,other,not separately reimbusable,138.91,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,166.91,100,,,fee schedule,100% of cigna custom fee schedule,152.8,110,,,fee schedule,110% of cms physician fee schedule,140.3,101,,,fee schedule,101% of cms physician fee schedule ,140.3,116.15,,,fee schedule,116.51% of cms physician fee schedule,140.3,101,,,fee schedule,101% of cms physician fee schedule,263.93,110,,,fee schedule,110% of humana physician fee schedule,152.8,110,,,fee schedule,110% of humana physician fee schedule,208.37,150,,,fee schedule,100% of cms fee schedule,138.91,100,,,fee schedule,100% of cms physician fee schedule,208.37,150,,,fee schedule,150% of cms physician fee schedule,100,208.37,
EXC MAL LES T/A/L 0.6-1.0,43600207,CDM,981,RC,11601,HCPCS,outpatient,,,506.25,303.75,,,,,,other,not separately reimbusable,140.53,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,173.7,100,,,fee schedule,100% of cigna custom fee schedule,154.58,110,,,fee schedule,110% of cms physician fee schedule,141.94,101,,,fee schedule,101% of cms physician fee schedule ,141.94,116.15,,,fee schedule,116.51% of cms physician fee schedule,141.94,101,,,fee schedule,101% of cms physician fee schedule,267.01,110,,,fee schedule,110% of humana physician fee schedule,154.58,110,,,fee schedule,110% of humana physician fee schedule,210.8,150,,,fee schedule,100% of cms fee schedule,140.53,100,,,fee schedule,100% of cms physician fee schedule,210.8,150,,,fee schedule,150% of cms physician fee schedule,100,210.8,
EXC MAL LES T/A/L 1.1-2.0,43600208,CDM,981,RC,11602,HCPCS,outpatient,,,506.25,303.75,,,,,,other,not separately reimbusable,152.44,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,190.69,100,,,fee schedule,100% of cigna custom fee schedule,167.68,110,,,fee schedule,110% of cms physician fee schedule,153.96,101,,,fee schedule,101% of cms physician fee schedule ,153.96,116.15,,,fee schedule,116.51% of cms physician fee schedule,153.96,101,,,fee schedule,101% of cms physician fee schedule,289.64,110,,,fee schedule,110% of humana physician fee schedule,167.68,110,,,fee schedule,110% of humana physician fee schedule,228.66,150,,,fee schedule,100% of cms fee schedule,152.44,100,,,fee schedule,100% of cms physician fee schedule,228.66,150,,,fee schedule,150% of cms physician fee schedule,100,228.66,
EX MAL LES S/N/H/F/G1.1-2,43600211,CDM,981,RC,11622,HCPCS,outpatient,,,875,525.00,,,,,,other,not separately reimbusable,160.37,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,200.69,100,,,fee schedule,100% of cigna custom fee schedule,176.41,110,,,fee schedule,110% of cms physician fee schedule,161.97,101,,,fee schedule,101% of cms physician fee schedule ,161.97,116.15,,,fee schedule,116.51% of cms physician fee schedule,161.97,101,,,fee schedule,101% of cms physician fee schedule,304.7,110,,,fee schedule,110% of humana physician fee schedule,176.41,110,,,fee schedule,110% of humana physician fee schedule,240.56,150,,,fee schedule,100% of cms fee schedule,160.37,100,,,fee schedule,100% of cms physician fee schedule,240.56,150,,,fee schedule,150% of cms physician fee schedule,100,240.56,
AVUL NAIL PLT PAR/COM SGL,36010009,CDM,981,RC,11730,HCPCS,outpatient,,,126.25,75.75,,,,,,other,not separately reimbusable,51.79,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,65.26,100,,,fee schedule,100% of cigna custom fee schedule,56.97,110,,,fee schedule,110% of cms physician fee schedule,52.31,101,,,fee schedule,101% of cms physician fee schedule ,52.31,116.15,,,fee schedule,116.51% of cms physician fee schedule,52.31,101,,,fee schedule,101% of cms physician fee schedule,98.4,110,,,fee schedule,110% of humana physician fee schedule,56.97,110,,,fee schedule,110% of humana physician fee schedule,77.69,150,,,fee schedule,100% of cms fee schedule,51.79,100,,,fee schedule,100% of cms physician fee schedule,77.69,150,,,fee schedule,150% of cms physician fee schedule,51.79,150,
AVUL NAIL PLTE PAR/COMPLT,36011045,CDM,981,RC,11732,HCPCS,outpatient,,,107.5,64.50,,,,,,other,not separately reimbusable,16.41,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,21.19,100,,,fee schedule,100% of cigna custom fee schedule,18.05,110,,,fee schedule,110% of cms physician fee schedule,16.57,101,,,fee schedule,101% of cms physician fee schedule ,16.57,116.15,,,fee schedule,116.51% of cms physician fee schedule,16.57,101,,,fee schedule,101% of cms physician fee schedule,31.18,110,,,fee schedule,110% of humana physician fee schedule,18.05,110,,,fee schedule,110% of humana physician fee schedule,24.62,150,,,fee schedule,100% of cms fee schedule,16.41,100,,,fee schedule,100% of cms physician fee schedule,24.62,150,,,fee schedule,150% of cms physician fee schedule,16.41,150,
EVAC SUBUNGL HEMATOMA,36010010,CDM,981,RC,11740,HCPCS,outpatient,,,43.75,26.25,,,,,,other,not separately reimbusable,30.07,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,56.91,100,,,fee schedule,100% of cigna custom fee schedule,33.08,110,,,fee schedule,110% of cms physician fee schedule,30.37,101,,,fee schedule,101% of cms physician fee schedule ,30.37,116.15,,,fee schedule,116.51% of cms physician fee schedule,30.37,101,,,fee schedule,101% of cms physician fee schedule,57.13,110,,,fee schedule,110% of humana physician fee schedule,33.08,110,,,fee schedule,110% of humana physician fee schedule,45.11,150,,,fee schedule,100% of cms fee schedule,30.07,100,,,fee schedule,100% of cms physician fee schedule,45.11,150,,,fee schedule,150% of cms physician fee schedule,30.07,150,
EXC OF NAIL PARTIAL/COMPL,36010011,CDM,981,RC,11750,HCPCS,outpatient,,,506.25,303.75,,,,,,other,not separately reimbusable,96.91,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,200.74,100,,,fee schedule,100% of cigna custom fee schedule,106.6,110,,,fee schedule,110% of cms physician fee schedule,97.88,101,,,fee schedule,101% of cms physician fee schedule ,97.88,116.15,,,fee schedule,116.51% of cms physician fee schedule,97.88,101,,,fee schedule,101% of cms physician fee schedule,184.13,110,,,fee schedule,110% of humana physician fee schedule,106.6,110,,,fee schedule,110% of humana physician fee schedule,145.37,150,,,fee schedule,100% of cms fee schedule,96.91,100,,,fee schedule,100% of cms physician fee schedule,145.37,150,,,fee schedule,150% of cms physician fee schedule,96.91,150,
BIOPSY OF NAIL UNIT,43701726,CDM,982,RC,11755,HCPCS,outpatient,,,727.53,436.52,,,,,,other,not separately reimbusable,58.53,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,139.57,100,,,fee schedule,100% of cigna custom fee schedule,64.38,110,,,fee schedule,110% of cms physician fee schedule,59.12,101,,,fee schedule,101% of cms physician fee schedule ,59.12,116.15,,,fee schedule,116.51% of cms physician fee schedule,59.12,101,,,fee schedule,101% of cms physician fee schedule,111.21,110,,,fee schedule,110% of humana physician fee schedule,64.38,110,,,fee schedule,110% of humana physician fee schedule,87.8,150,,,fee schedule,100% of cms fee schedule,58.53,100,,,fee schedule,100% of cms physician fee schedule,87.8,150,,,fee schedule,150% of cms physician fee schedule,58.53,150,
SMP REP S/N/A/G/TR/E;2.5<,36010012,CDM,981,RC,12001,HCPCS,outpatient,,,128.75,77.25,,,,,,other,not separately reimbusable,43.96,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,52.74,100,,,fee schedule,100% of cigna custom fee schedule,48.36,110,,,fee schedule,110% of cms physician fee schedule,44.4,101,,,fee schedule,101% of cms physician fee schedule ,44.4,116.15,,,fee schedule,116.51% of cms physician fee schedule,44.4,101,,,fee schedule,101% of cms physician fee schedule,83.52,110,,,fee schedule,110% of humana physician fee schedule,48.36,110,,,fee schedule,110% of humana physician fee schedule,65.94,150,,,fee schedule,100% of cms fee schedule,43.96,100,,,fee schedule,100% of cms physician fee schedule,65.94,150,,,fee schedule,150% of cms physician fee schedule,43.96,150,
SMP RE S/N/A/G/T/E2.6-7.5,36010013,CDM,981,RC,12002,HCPCS,outpatient,,,128.75,77.25,,,,,,other,not separately reimbusable,57.98,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,69.96,100,,,fee schedule,100% of cigna custom fee schedule,63.78,110,,,fee schedule,110% of cms physician fee schedule,58.56,101,,,fee schedule,101% of cms physician fee schedule ,58.56,116.15,,,fee schedule,116.51% of cms physician fee schedule,58.56,101,,,fee schedule,101% of cms physician fee schedule,110.16,110,,,fee schedule,110% of humana physician fee schedule,63.78,110,,,fee schedule,110% of humana physician fee schedule,86.97,150,,,fee schedule,100% of cms fee schedule,57.98,100,,,fee schedule,100% of cms physician fee schedule,86.97,150,,,fee schedule,150% of cms physician fee schedule,57.98,150,
SMPRE S/N/A/G/T/E7.6-12.5,36010014,CDM,981,RC,12004,HCPCS,outpatient,,,130,78.00,,,,,,other,not separately reimbusable,72.68,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,87.69,100,,,fee schedule,100% of cigna custom fee schedule,79.95,110,,,fee schedule,110% of cms physician fee schedule,73.41,101,,,fee schedule,101% of cms physician fee schedule ,73.41,116.15,,,fee schedule,116.51% of cms physician fee schedule,73.41,101,,,fee schedule,101% of cms physician fee schedule,138.09,110,,,fee schedule,110% of humana physician fee schedule,79.95,110,,,fee schedule,110% of humana physician fee schedule,109.02,150,,,fee schedule,100% of cms fee schedule,72.68,100,,,fee schedule,100% of cms physician fee schedule,109.02,150,,,fee schedule,150% of cms physician fee schedule,72.68,150,
SMPRE S/N/A/G/T/E12.6-20,36010015,CDM,981,RC,12005,HCPCS,outpatient,,,130,78.00,,,,,,other,not separately reimbusable,94.22,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,177.49,100,,,fee schedule,100% of cigna custom fee schedule,103.64,110,,,fee schedule,110% of cms physician fee schedule,95.16,101,,,fee schedule,101% of cms physician fee schedule ,95.16,116.15,,,fee schedule,116.51% of cms physician fee schedule,95.16,101,,,fee schedule,101% of cms physician fee schedule,179.02,110,,,fee schedule,110% of humana physician fee schedule,103.64,110,,,fee schedule,110% of humana physician fee schedule,141.33,150,,,fee schedule,100% of cms fee schedule,94.22,100,,,fee schedule,100% of cms physician fee schedule,141.33,150,,,fee schedule,150% of cms physician fee schedule,94.22,150,
SMP REP F/E/N/L/MM;2.5CM<,36010016,CDM,981,RC,12011,HCPCS,outpatient,,,127.5,76.50,,,,,,other,not separately reimbusable,54.69,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,101.96,100,,,fee schedule,100% of cigna custom fee schedule,60.16,110,,,fee schedule,110% of cms physician fee schedule,55.24,101,,,fee schedule,101% of cms physician fee schedule ,55.24,116.15,,,fee schedule,116.51% of cms physician fee schedule,55.24,101,,,fee schedule,101% of cms physician fee schedule,103.91,110,,,fee schedule,110% of humana physician fee schedule,60.16,110,,,fee schedule,110% of humana physician fee schedule,82.04,150,,,fee schedule,100% of cms fee schedule,54.69,100,,,fee schedule,100% of cms physician fee schedule,82.04,150,,,fee schedule,150% of cms physician fee schedule,54.69,150,
SMP REP F/E/N/L/MM;2.6-5,36010017,CDM,981,RC,12013,HCPCS,outpatient,,,130,78.00,,,,,,other,not separately reimbusable,57.62,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,108.08,100,,,fee schedule,100% of cigna custom fee schedule,63.38,110,,,fee schedule,110% of cms physician fee schedule,58.2,101,,,fee schedule,101% of cms physician fee schedule ,58.2,116.15,,,fee schedule,116.51% of cms physician fee schedule,58.2,101,,,fee schedule,101% of cms physician fee schedule,109.48,110,,,fee schedule,110% of humana physician fee schedule,63.38,110,,,fee schedule,110% of humana physician fee schedule,86.43,150,,,fee schedule,100% of cms fee schedule,57.62,100,,,fee schedule,100% of cms physician fee schedule,86.43,150,,,fee schedule,150% of cms physician fee schedule,57.62,150,
PHY I&D OUTER EAR ABSCESS,36013013,CDM,981,RC,69020,HCPCS,outpatient,,,175,105.00,,,,,,other,not separately reimbusable,135.41,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,257.25,100,,,fee schedule,100% of cigna custom fee schedule,148.95,110,,,fee schedule,110% of cms physician fee schedule,136.76,101,,,fee schedule,101% of cms physician fee schedule ,136.76,116.15,,,fee schedule,116.51% of cms physician fee schedule,136.76,101,,,fee schedule,101% of cms physician fee schedule,257.28,110,,,fee schedule,110% of humana physician fee schedule,148.95,110,,,fee schedule,110% of humana physician fee schedule,203.12,150,,,fee schedule,100% of cms fee schedule,135.41,100,,,fee schedule,100% of cms physician fee schedule,203.12,150,,,fee schedule,150% of cms physician fee schedule,100,203.12,
SMPRE F/E/N/L/MM;5.1-7.5,36010151,CDM,981,RC,12014,HCPCS,outpatient,,,130,78.00,,,,,,other,not separately reimbusable,74.65,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,139.33,100,,,fee schedule,100% of cigna custom fee schedule,82.12,110,,,fee schedule,110% of cms physician fee schedule,75.4,101,,,fee schedule,101% of cms physician fee schedule ,75.4,116.15,,,fee schedule,116.51% of cms physician fee schedule,75.4,101,,,fee schedule,101% of cms physician fee schedule,141.84,110,,,fee schedule,110% of humana physician fee schedule,82.12,110,,,fee schedule,110% of humana physician fee schedule,111.98,150,,,fee schedule,100% of cms fee schedule,74.65,100,,,fee schedule,100% of cms physician fee schedule,111.98,150,,,fee schedule,150% of cms physician fee schedule,74.65,150,
SMPRE F/E/N/L/MM;7.5-12.5,36010164,CDM,981,RC,12015,HCPCS,outpatient,,,130,78.00,,,,,,other,not separately reimbusable,93.68,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,175.83,100,,,fee schedule,100% of cigna custom fee schedule,103.05,110,,,fee schedule,110% of cms physician fee schedule,94.62,101,,,fee schedule,101% of cms physician fee schedule ,94.62,116.15,,,fee schedule,116.51% of cms physician fee schedule,94.62,101,,,fee schedule,101% of cms physician fee schedule,177.99,110,,,fee schedule,110% of humana physician fee schedule,103.05,110,,,fee schedule,110% of humana physician fee schedule,140.52,150,,,fee schedule,100% of cms fee schedule,93.68,100,,,fee schedule,100% of cms physician fee schedule,140.52,150,,,fee schedule,150% of cms physician fee schedule,93.68,150,
INTMD WND REP S/T/EXT2.5<,36010018,CDM,981,RC,12031,HCPCS,outpatient,,,377.5,226.50,,,,,,other,not separately reimbusable,142.87,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,275.12,100,,,fee schedule,100% of cigna custom fee schedule,157.16,110,,,fee schedule,110% of cms physician fee schedule,144.3,101,,,fee schedule,101% of cms physician fee schedule ,144.3,116.15,,,fee schedule,116.51% of cms physician fee schedule,144.3,101,,,fee schedule,101% of cms physician fee schedule,271.45,110,,,fee schedule,110% of humana physician fee schedule,157.16,110,,,fee schedule,110% of humana physician fee schedule,214.31,150,,,fee schedule,100% of cms fee schedule,142.87,100,,,fee schedule,100% of cms physician fee schedule,214.31,150,,,fee schedule,150% of cms physician fee schedule,100,214.31,
INT WND RE S/A/T/E2.6-7.5,36010019,CDM,981,RC,12032,HCPCS,outpatient,,,377.5,226.50,,,,,,other,not separately reimbusable,179.19,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,350.09,100,,,fee schedule,100% of cigna custom fee schedule,197.11,110,,,fee schedule,110% of cms physician fee schedule,180.98,101,,,fee schedule,101% of cms physician fee schedule ,180.98,116.15,,,fee schedule,116.51% of cms physician fee schedule,180.98,101,,,fee schedule,101% of cms physician fee schedule,340.46,110,,,fee schedule,110% of humana physician fee schedule,197.11,110,,,fee schedule,110% of humana physician fee schedule,268.79,150,,,fee schedule,100% of cms fee schedule,179.19,100,,,fee schedule,100% of cms physician fee schedule,268.79,150,,,fee schedule,150% of cms physician fee schedule,100,268.79,
SHAVE SKN LES 1.1-2.0,43601701,CDM,981,RC,11302,HCPCS,outpatient,,,107.5,64.50,,,,,,other,not separately reimbusable,56.92,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,74.75,100,,,fee schedule,100% of cigna custom fee schedule,62.61,110,,,fee schedule,110% of cms physician fee schedule,57.49,101,,,fee schedule,101% of cms physician fee schedule ,57.49,116.15,,,fee schedule,116.51% of cms physician fee schedule,57.49,101,,,fee schedule,101% of cms physician fee schedule,108.15,110,,,fee schedule,110% of humana physician fee schedule,62.61,110,,,fee schedule,110% of humana physician fee schedule,85.38,150,,,fee schedule,100% of cms fee schedule,56.92,100,,,fee schedule,100% of cms physician fee schedule,85.38,150,,,fee schedule,150% of cms physician fee schedule,56.92,150,
INTMD WND RPR 12.6-20.0CM,36010139,CDM,981,RC,12035,HCPCS,outpatient,,,377.5,226.50,,,,,,other,not separately reimbusable,231.18,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,436.11,100,,,fee schedule,100% of cigna custom fee schedule,254.3,110,,,fee schedule,110% of cms physician fee schedule,233.49,101,,,fee schedule,101% of cms physician fee schedule ,233.49,116.15,,,fee schedule,116.51% of cms physician fee schedule,233.49,101,,,fee schedule,101% of cms physician fee schedule,439.24,110,,,fee schedule,110% of humana physician fee schedule,254.3,110,,,fee schedule,110% of humana physician fee schedule,346.77,150,,,fee schedule,100% of cms fee schedule,231.18,100,,,fee schedule,100% of cms physician fee schedule,346.77,150,,,fee schedule,150% of cms physician fee schedule,100,346.77,
INT WND REP N-HF/GEN 2.5<,36010021,CDM,981,RC,12041,HCPCS,outpatient,,,302,181.20,,,,,,other,not separately reimbusable,137.83,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,271.82,100,,,fee schedule,100% of cigna custom fee schedule,151.61,110,,,fee schedule,110% of cms physician fee schedule,139.21,101,,,fee schedule,101% of cms physician fee schedule ,139.21,116.15,,,fee schedule,116.51% of cms physician fee schedule,139.21,101,,,fee schedule,101% of cms physician fee schedule,261.88,110,,,fee schedule,110% of humana physician fee schedule,151.61,110,,,fee schedule,110% of humana physician fee schedule,206.75,150,,,fee schedule,100% of cms fee schedule,137.83,100,,,fee schedule,100% of cms physician fee schedule,206.75,150,,,fee schedule,150% of cms physician fee schedule,100,206.75,
INT REP N-HF/GEN 2.6-7.5,36010022,CDM,981,RC,12042,HCPCS,outpatient,,,377.5,226.50,,,,,,other,not separately reimbusable,185.33,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,362.68,100,,,fee schedule,100% of cigna custom fee schedule,203.86,110,,,fee schedule,110% of cms physician fee schedule,187.18,101,,,fee schedule,101% of cms physician fee schedule ,187.18,116.15,,,fee schedule,116.51% of cms physician fee schedule,187.18,101,,,fee schedule,101% of cms physician fee schedule,352.13,110,,,fee schedule,110% of humana physician fee schedule,203.86,110,,,fee schedule,110% of humana physician fee schedule,278,150,,,fee schedule,100% of cms fee schedule,185.33,100,,,fee schedule,100% of cms physician fee schedule,278,150,,,fee schedule,150% of cms physician fee schedule,100,278,
INTERMEDIATE REPAIR FACE/MM 2.5/<,36010023,CDM,981,RC,12051,HCPCS,outpatient,,,377.5,226.50,,,,,,other,not separately reimbusable,160.51,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,308.9,100,,,fee schedule,100% of cigna custom fee schedule,176.56,110,,,fee schedule,110% of cms physician fee schedule,162.12,101,,,fee schedule,101% of cms physician fee schedule ,162.12,116.15,,,fee schedule,116.51% of cms physician fee schedule,162.12,101,,,fee schedule,101% of cms physician fee schedule,304.97,110,,,fee schedule,110% of humana physician fee schedule,176.56,110,,,fee schedule,110% of humana physician fee schedule,240.77,150,,,fee schedule,100% of cms fee schedule,160.51,100,,,fee schedule,100% of cms physician fee schedule,240.77,150,,,fee schedule,150% of cms physician fee schedule,100,240.77,
INTMD RPR FACE/MM 2.6-5.0 CM,36010024,CDM,981,RC,12052,HCPCS,outpatient,,,397.2,238.32,,,,,,other,not separately reimbusable,189.05,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,369.24,100,,,fee schedule,100% of cigna custom fee schedule,207.96,110,,,fee schedule,110% of cms physician fee schedule,190.94,101,,,fee schedule,101% of cms physician fee schedule ,190.94,116.15,,,fee schedule,116.51% of cms physician fee schedule,190.94,101,,,fee schedule,101% of cms physician fee schedule,359.2,110,,,fee schedule,110% of humana physician fee schedule,207.96,110,,,fee schedule,110% of humana physician fee schedule,283.58,150,,,fee schedule,100% of cms fee schedule,189.05,100,,,fee schedule,100% of cms physician fee schedule,283.58,150,,,fee schedule,150% of cms physician fee schedule,100,283.58,
INT WND REP FCE-MM5.1-7.5,36010132,CDM,981,RC,12053,HCPCS,outpatient,,,521.25,312.75,,,,,,other,not separately reimbusable,204.44,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,394.93,100,,,fee schedule,100% of cigna custom fee schedule,224.88,110,,,fee schedule,110% of cms physician fee schedule,206.48,101,,,fee schedule,101% of cms physician fee schedule ,206.48,116.15,,,fee schedule,116.51% of cms physician fee schedule,206.48,101,,,fee schedule,101% of cms physician fee schedule,388.44,110,,,fee schedule,110% of humana physician fee schedule,224.88,110,,,fee schedule,110% of humana physician fee schedule,306.66,150,,,fee schedule,100% of cms fee schedule,204.44,100,,,fee schedule,100% of cms physician fee schedule,306.66,150,,,fee schedule,150% of cms physician fee schedule,100,306.66,
SKIN SUB GRAFT TRNK/ARM/LEG,44500051,CDM,981,RC,15271,HCPCS,outpatient,,,4233.63,2540.18,,,,,,other,not separately reimbusable,81.05,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,100.77,100,,,fee schedule,100% of cigna custom fee schedule,89.16,110,,,fee schedule,110% of cms physician fee schedule,81.86,101,,,fee schedule,101% of cms physician fee schedule ,81.86,116.15,,,fee schedule,116.51% of cms physician fee schedule,81.86,101,,,fee schedule,101% of cms physician fee schedule,154,110,,,fee schedule,110% of humana physician fee schedule,89.16,110,,,fee schedule,110% of humana physician fee schedule,121.58,150,,,fee schedule,100% of cms fee schedule,81.05,100,,,fee schedule,100% of cms physician fee schedule,121.58,150,,,fee schedule,150% of cms physician fee schedule,81.05,150,
INIT TMT 1ST DEGREE BURN,36010025,CDM,981,RC,16000,HCPCS,outpatient,,,97.26,58.36,,,,,,other,not separately reimbusable,44.57,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,54.84,100,,,fee schedule,100% of cigna custom fee schedule,49.03,110,,,fee schedule,110% of cms physician fee schedule,45.02,101,,,fee schedule,101% of cms physician fee schedule ,45.02,116.15,,,fee schedule,116.51% of cms physician fee schedule,45.02,101,,,fee schedule,101% of cms physician fee schedule,84.68,110,,,fee schedule,110% of humana physician fee schedule,49.03,110,,,fee schedule,110% of humana physician fee schedule,66.86,150,,,fee schedule,100% of cms fee schedule,44.57,100,,,fee schedule,100% of cms physician fee schedule,66.86,150,,,fee schedule,150% of cms physician fee schedule,44.57,150,
OUTPATIENT NEG PRESS WOUND TX 50CM,44500004,CDM,761,RC,97605,HCPCS,outpatient,,,353.49,212.09,,212.09,60,,169.672,percent of total billed charges,60% of total billed charges,169.68,48,,135.744,percent of total billed charges,48% of total billed charges,137.87,100,,,fee schedule,100% of bcbs custom fee schedule,137.87,100,,,fee schedule,100% of bcbs custom fee schedule,153.04,111,,,fee schedule,111% of bcbs custom fee schedule,176.75,50,,141.4,percent of total billed charges,50% of total billed charges,247.44,70,,197.952,percent of total billed charges,70% of total billed charges,171.37,48.48,,137.096,percent of total billed charges,48.48% of total billed charges,27.12,116.15,,,fee schedule,116.51% of cms physician fee schedule,171.37,48.48,,137.096,percent of total billed charges,48.48% of total billed charges,247.44,70,,197.952,percent of total billed charges,70% of total billed charges,247.44,70,,197.952,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,171.37,48.48,,137.096,percent of total billed charges,48.48% of total billed charges,318.14,90,,254.512,percent of total billed charges,90% of total billed charges,48.48,318.14,
PHY NEG PRESS WOUND TX >50CM,44500005,CDM,981,RC,97606,HCPCS,outpatient,,,55.56,33.34,,,,,,other,not separately reimbusable,25.6,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,14.94,100,,,fee schedule,100% of cigna custom fee schedule,48.64,110,,,fee schedule,110% of cms physician fee schedule,25.86,101,,,fee schedule,101% of cms physician fee schedule ,25.86,116.15,,,fee schedule,116.51% of cms physician fee schedule,25.86,101,,,fee schedule,101% of cms physician fee schedule,20.48,80,,,fee schedule,80% of humana physician fee schedule,20.48,110,,,fee schedule,110% of humana physician fee schedule,38.4,150,,,fee schedule,100% of cms fee schedule,25.6,100,,,fee schedule,100% of cms physician fee schedule,38.4,150,,,fee schedule,150% of cms physician fee schedule,25.6,150,
SKIN SUB GRAFT T/A/L ADD ON,44500052,CDM,981,RC,15272,HCPCS,outpatient,,,4233.63,2540.18,,,,,,other,not separately reimbusable,16.38,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,20.85,100,,,fee schedule,100% of cigna custom fee schedule,18.02,110,,,fee schedule,110% of cms physician fee schedule,16.54,101,,,fee schedule,101% of cms physician fee schedule ,16.54,116.15,,,fee schedule,116.51% of cms physician fee schedule,16.54,101,,,fee schedule,101% of cms physician fee schedule,31.12,110,,,fee schedule,110% of humana physician fee schedule,18.02,110,,,fee schedule,110% of humana physician fee schedule,24.57,150,,,fee schedule,100% of cms fee schedule,16.38,100,,,fee schedule,100% of cms physician fee schedule,24.57,150,,,fee schedule,150% of cms physician fee schedule,16.38,150,
SKIN SUB GRFT T/ARM/LG CHILD,44500053,CDM,981,RC,15273,HCPCS,outpatient,,,6412.47,3847.48,,,,,,other,not separately reimbusable,189.28,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,243.83,100,,,fee schedule,100% of cigna custom fee schedule,208.21,110,,,fee schedule,110% of cms physician fee schedule,191.17,101,,,fee schedule,101% of cms physician fee schedule ,191.17,116.15,,,fee schedule,116.51% of cms physician fee schedule,191.17,101,,,fee schedule,101% of cms physician fee schedule,359.63,110,,,fee schedule,110% of humana physician fee schedule,208.21,110,,,fee schedule,110% of humana physician fee schedule,283.92,150,,,fee schedule,100% of cms fee schedule,189.28,100,,,fee schedule,100% of cms physician fee schedule,283.92,150,,,fee schedule,150% of cms physician fee schedule,100,283.92,
SKIN SUB GRFT T/A/L CHILD ADD ON,44500054,CDM,981,RC,15274,HCPCS,outpatient,,,99.62,59.77,,,,,,other,not separately reimbusable,43.3,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,55.58,100,,,fee schedule,100% of cigna custom fee schedule,47.63,110,,,fee schedule,110% of cms physician fee schedule,43.73,101,,,fee schedule,101% of cms physician fee schedule ,43.73,116.15,,,fee schedule,116.51% of cms physician fee schedule,43.73,101,,,fee schedule,101% of cms physician fee schedule,82.27,110,,,fee schedule,110% of humana physician fee schedule,47.63,110,,,fee schedule,110% of humana physician fee schedule,64.95,150,,,fee schedule,100% of cms fee schedule,43.3,100,,,fee schedule,100% of cms physician fee schedule,64.95,150,,,fee schedule,150% of cms physician fee schedule,43.3,150,
DEBRDE P-THCK BRN SMALL,36010026,CDM,981,RC,16020,HCPCS,outpatient,,,353.49,212.09,,,,,,other,not separately reimbusable,52.98,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,96.36,100,,,fee schedule,100% of cigna custom fee schedule,58.28,110,,,fee schedule,110% of cms physician fee schedule,53.51,101,,,fee schedule,101% of cms physician fee schedule ,53.51,116.15,,,fee schedule,116.51% of cms physician fee schedule,53.51,101,,,fee schedule,101% of cms physician fee schedule,100.66,110,,,fee schedule,110% of humana physician fee schedule,58.28,110,,,fee schedule,110% of humana physician fee schedule,79.47,150,,,fee schedule,100% of cms fee schedule,52.98,100,,,fee schedule,100% of cms physician fee schedule,79.47,150,,,fee schedule,150% of cms physician fee schedule,52.98,150,
CHEMICAL CAUTERY TISSUE,36010260,CDM,981,RC,17250,HCPCS,outpatient,,,72,43.20,,,,,,other,not separately reimbusable,35.72,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,42.78,100,,,fee schedule,100% of cigna custom fee schedule,39.29,110,,,fee schedule,110% of cms physician fee schedule,36.08,101,,,fee schedule,101% of cms physician fee schedule ,36.08,116.15,,,fee schedule,116.51% of cms physician fee schedule,36.08,101,,,fee schedule,101% of cms physician fee schedule,67.87,110,,,fee schedule,110% of humana physician fee schedule,39.29,110,,,fee schedule,110% of humana physician fee schedule,53.58,150,,,fee schedule,100% of cms fee schedule,35.72,100,,,fee schedule,100% of cms physician fee schedule,53.58,150,,,fee schedule,150% of cms physician fee schedule,35.72,150,
DEBRDE P-THCK BRN MEDIUM,36010027,CDM,981,RC,16025,HCPCS,outpatient,,,161.25,96.75,,,,,,other,not separately reimbusable,107.16,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,202.27,100,,,fee schedule,100% of cigna custom fee schedule,117.88,110,,,fee schedule,110% of cms physician fee schedule,108.23,101,,,fee schedule,101% of cms physician fee schedule ,108.23,116.15,,,fee schedule,116.51% of cms physician fee schedule,108.23,101,,,fee schedule,101% of cms physician fee schedule,203.6,110,,,fee schedule,110% of humana physician fee schedule,117.88,110,,,fee schedule,110% of humana physician fee schedule,160.74,150,,,fee schedule,100% of cms fee schedule,107.16,100,,,fee schedule,100% of cms physician fee schedule,160.74,150,,,fee schedule,150% of cms physician fee schedule,100,160.74,
DESTR PRE-MAL LES 1ST LES,43601127,CDM,981,RC,17000,HCPCS,outpatient,,,155,93.00,,,,,,other,not separately reimbusable,51.45,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,60.56,100,,,fee schedule,100% of cigna custom fee schedule,56.6,110,,,fee schedule,110% of cms physician fee schedule,51.96,101,,,fee schedule,101% of cms physician fee schedule ,51.96,116.15,,,fee schedule,116.51% of cms physician fee schedule,51.96,101,,,fee schedule,101% of cms physician fee schedule,97.76,110,,,fee schedule,110% of humana physician fee schedule,56.6,110,,,fee schedule,110% of humana physician fee schedule,77.18,150,,,fee schedule,100% of cms fee schedule,51.45,100,,,fee schedule,100% of cms physician fee schedule,77.18,150,,,fee schedule,150% of cms physician fee schedule,51.45,150,
SKIN SUB GRFT F/N/HF/G/ADDL,44500056,CDM,981,RC,15276,HCPCS,outpatient,,,236.39,141.83,,,,,,other,not separately reimbusable,24.26,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,30.35,100,,,fee schedule,100% of cigna custom fee schedule,26.69,110,,,fee schedule,110% of cms physician fee schedule,24.5,101,,,fee schedule,101% of cms physician fee schedule ,24.5,116.15,,,fee schedule,116.51% of cms physician fee schedule,24.5,101,,,fee schedule,101% of cms physician fee schedule,46.09,110,,,fee schedule,110% of humana physician fee schedule,26.69,110,,,fee schedule,110% of humana physician fee schedule,36.39,150,,,fee schedule,100% of cms fee schedule,24.26,100,,,fee schedule,100% of cms physician fee schedule,36.39,150,,,fee schedule,150% of cms physician fee schedule,24.26,150,
DESTRU B9 LESION UP TO 14,43601152,CDM,981,RC,17110,HCPCS,outpatient,,,140,84.00,,,,,,other,not separately reimbusable,63.87,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,79,100,,,fee schedule,100% of cigna custom fee schedule,70.26,110,,,fee schedule,110% of cms physician fee schedule,64.51,101,,,fee schedule,101% of cms physician fee schedule ,64.51,116.15,,,fee schedule,116.51% of cms physician fee schedule,64.51,101,,,fee schedule,101% of cms physician fee schedule,121.35,110,,,fee schedule,110% of humana physician fee schedule,70.26,110,,,fee schedule,110% of humana physician fee schedule,95.81,150,,,fee schedule,100% of cms fee schedule,63.87,100,,,fee schedule,100% of cms physician fee schedule,95.81,150,,,fee schedule,150% of cms physician fee schedule,63.87,150,
SKIN SUB GRAFT F/N/HF/G/ADDL,44500056,CDM,981,RC,15276,HCPCS,outpatient,,,1083.9,650.34,,,,,,other,not separately reimbusable,24.26,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,30.35,100,,,fee schedule,100% of cigna custom fee schedule,26.69,110,,,fee schedule,110% of cms physician fee schedule,24.5,101,,,fee schedule,101% of cms physician fee schedule ,24.5,116.15,,,fee schedule,116.51% of cms physician fee schedule,24.5,101,,,fee schedule,101% of cms physician fee schedule,46.09,110,,,fee schedule,110% of humana physician fee schedule,26.69,110,,,fee schedule,110% of humana physician fee schedule,36.39,150,,,fee schedule,100% of cms fee schedule,24.26,100,,,fee schedule,100% of cms physician fee schedule,36.39,150,,,fee schedule,150% of cms physician fee schedule,24.26,150,
SKIN SUB GRFT F/N/HF/G/CHILD,44500057,CDM,981,RC,15277,HCPCS,outpatient,,,641.53,384.92,,,,,,other,not separately reimbusable,215.68,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,273.05,100,,,fee schedule,100% of cigna custom fee schedule,237.25,110,,,fee schedule,110% of cms physician fee schedule,217.84,101,,,fee schedule,101% of cms physician fee schedule ,217.84,116.15,,,fee schedule,116.51% of cms physician fee schedule,217.84,101,,,fee schedule,101% of cms physician fee schedule,409.79,110,,,fee schedule,110% of humana physician fee schedule,237.25,110,,,fee schedule,110% of humana physician fee schedule,323.52,150,,,fee schedule,100% of cms fee schedule,215.68,100,,,fee schedule,100% of cms physician fee schedule,323.52,150,,,fee schedule,150% of cms physician fee schedule,100,323.52,
OUTPT NEW VISIT,43600132,CDM,981,RC,99205,HCPCS,outpatient,,,348.3,208.98,,,,,,other,not separately reimbusable,174.85,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,164.93,100,,,fee schedule,100% of cigna custom fee schedule,192.34,110,,,fee schedule,110% of cms physician fee schedule,176.6,101,,,fee schedule,101% of cms physician fee schedule ,176.6,116.15,,,fee schedule,116.51% of cms physician fee schedule,176.6,101,,,fee schedule,101% of cms physician fee schedule,332.22,110,,,fee schedule,110% of humana physician fee schedule,192.34,110,,,fee schedule,110% of humana physician fee schedule,262.28,150,,,fee schedule,100% of cms fee schedule,174.85,100,,,fee schedule,100% of cms physician fee schedule,262.28,150,,,fee schedule,150% of cms physician fee schedule,100,262.28,
ASPIRATION CYST OF BREAST,36010029,CDM,981,RC,19000,HCPCS,outpatient,,,410,246.00,,,,,,other,not separately reimbusable,40.89,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,81.02,100,,,fee schedule,100% of cigna custom fee schedule,44.98,110,,,fee schedule,110% of cms physician fee schedule,41.3,101,,,fee schedule,101% of cms physician fee schedule ,41.3,116.15,,,fee schedule,116.51% of cms physician fee schedule,41.3,101,,,fee schedule,101% of cms physician fee schedule,77.69,110,,,fee schedule,110% of humana physician fee schedule,44.98,110,,,fee schedule,110% of humana physician fee schedule,61.34,150,,,fee schedule,100% of cms fee schedule,40.89,100,,,fee schedule,100% of cms physician fee schedule,61.34,150,,,fee schedule,150% of cms physician fee schedule,40.89,150,
INJ(s) TRIGGR PNT 1-2 MUS,43701661,CDM,981,RC,20552,HCPCS,outpatient,,,481.56,288.94,,,,,,other,not separately reimbusable,35.51,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,71.37,100,,,fee schedule,100% of cigna custom fee schedule,39.06,110,,,fee schedule,110% of cms physician fee schedule,35.87,101,,,fee schedule,101% of cms physician fee schedule ,35.87,116.15,,,fee schedule,116.51% of cms physician fee schedule,35.87,101,,,fee schedule,101% of cms physician fee schedule,67.47,110,,,fee schedule,110% of humana physician fee schedule,39.06,110,,,fee schedule,110% of humana physician fee schedule,53.27,150,,,fee schedule,100% of cms fee schedule,35.51,100,,,fee schedule,100% of cms physician fee schedule,53.27,150,,,fee schedule,150% of cms physician fee schedule,35.51,150,
DRAIN/INJECT SM JNT/BURSA,36010163,CDM,981,RC,20600,HCPCS,outpatient,,,383.75,230.25,,,,,,other,not separately reimbusable,34.72,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,67.2,100,,,fee schedule,100% of cigna custom fee schedule,38.19,110,,,fee schedule,110% of cms physician fee schedule,35.07,101,,,fee schedule,101% of cms physician fee schedule ,35.07,116.15,,,fee schedule,116.51% of cms physician fee schedule,35.07,101,,,fee schedule,101% of cms physician fee schedule,65.97,110,,,fee schedule,110% of humana physician fee schedule,38.19,110,,,fee schedule,110% of humana physician fee schedule,52.08,150,,,fee schedule,100% of cms fee schedule,34.72,100,,,fee schedule,100% of cms physician fee schedule,52.08,150,,,fee schedule,150% of cms physician fee schedule,34.72,150,
DRAIN/INJ INTERM JNT/BURS,36010143,CDM,981,RC,20605,HCPCS,outpatient,,,383.75,230.25,,,,,,other,not separately reimbusable,35.68,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,70.54,100,,,fee schedule,100% of cigna custom fee schedule,39.25,110,,,fee schedule,110% of cms physician fee schedule,36.04,101,,,fee schedule,101% of cms physician fee schedule ,36.04,116.15,,,fee schedule,116.51% of cms physician fee schedule,36.04,101,,,fee schedule,101% of cms physician fee schedule,67.79,110,,,fee schedule,110% of humana physician fee schedule,39.25,110,,,fee schedule,110% of humana physician fee schedule,53.52,150,,,fee schedule,100% of cms fee schedule,35.68,100,,,fee schedule,100% of cms physician fee schedule,53.52,150,,,fee schedule,150% of cms physician fee schedule,35.68,150,
INJ/ASPI MAJOR JOINT,35010107,CDM,981,RC,20610,HCPCS,outpatient,,,383.75,230.25,,,,,,other,not separately reimbusable,44.07,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,87.7,100,,,fee schedule,100% of cigna custom fee schedule,48.48,110,,,fee schedule,110% of cms physician fee schedule,44.51,101,,,fee schedule,101% of cms physician fee schedule ,44.51,116.15,,,fee schedule,116.51% of cms physician fee schedule,44.51,101,,,fee schedule,101% of cms physician fee schedule,83.73,110,,,fee schedule,110% of humana physician fee schedule,48.48,110,,,fee schedule,110% of humana physician fee schedule,66.11,150,,,fee schedule,100% of cms fee schedule,44.07,100,,,fee schedule,100% of cms physician fee schedule,66.11,150,,,fee schedule,150% of cms physician fee schedule,44.07,150,
ASP/INJ GANGLION ANY SITE,36011052,CDM,981,RC,20612,HCPCS,outpatient,,,332.68,199.61,,,,,,other,not separately reimbusable,39.64,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,78.65,100,,,fee schedule,100% of cigna custom fee schedule,43.6,110,,,fee schedule,110% of cms physician fee schedule,40.04,101,,,fee schedule,101% of cms physician fee schedule ,40.04,116.15,,,fee schedule,116.51% of cms physician fee schedule,40.04,101,,,fee schedule,101% of cms physician fee schedule,75.32,110,,,fee schedule,110% of humana physician fee schedule,43.6,110,,,fee schedule,110% of humana physician fee schedule,59.46,150,,,fee schedule,100% of cms fee schedule,39.64,100,,,fee schedule,100% of cms physician fee schedule,59.46,150,,,fee schedule,150% of cms physician fee schedule,39.64,150,
TRMNT CLOSED SHOULDER DIS,36010036,CDM,981,RC,23650,HCPCS,outpatient,,,300,180.00,,,,,,other,not separately reimbusable,295.18,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,526.32,100,,,fee schedule,100% of cigna custom fee schedule,324.7,110,,,fee schedule,110% of cms physician fee schedule,298.13,101,,,fee schedule,101% of cms physician fee schedule ,298.13,116.15,,,fee schedule,116.51% of cms physician fee schedule,298.13,101,,,fee schedule,101% of cms physician fee schedule,560.84,110,,,fee schedule,110% of humana physician fee schedule,324.7,110,,,fee schedule,110% of humana physician fee schedule,442.77,150,,,fee schedule,100% of cms fee schedule,295.18,100,,,fee schedule,100% of cms physician fee schedule,442.77,150,,,fee schedule,150% of cms physician fee schedule,100,442.77,
I&D FINGER/ABCESS;SMPLE,36011037,CDM,981,RC,26010,HCPCS,outpatient,,,188.75,113.25,,,,,,other,not separately reimbusable,134.35,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,250.27,100,,,fee schedule,100% of cigna custom fee schedule,147.79,110,,,fee schedule,110% of cms physician fee schedule,135.69,101,,,fee schedule,101% of cms physician fee schedule ,135.69,116.15,,,fee schedule,116.51% of cms physician fee schedule,135.69,101,,,fee schedule,101% of cms physician fee schedule,255.27,110,,,fee schedule,110% of humana physician fee schedule,147.79,110,,,fee schedule,110% of humana physician fee schedule,201.53,150,,,fee schedule,100% of cms fee schedule,134.35,100,,,fee schedule,100% of cms physician fee schedule,201.53,150,,,fee schedule,150% of cms physician fee schedule,100,201.53,
I&D FINGER ABSCESS; COMP,36010274,CDM,981,RC,26011,HCPCS,outpatient,,,783.75,470.25,,,,,,other,not separately reimbusable,177.07,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,340.14,100,,,fee schedule,100% of cigna custom fee schedule,194.78,110,,,fee schedule,110% of cms physician fee schedule,178.84,101,,,fee schedule,101% of cms physician fee schedule ,178.84,116.15,,,fee schedule,116.51% of cms physician fee schedule,178.84,101,,,fee schedule,101% of cms physician fee schedule,336.43,110,,,fee schedule,110% of humana physician fee schedule,194.78,110,,,fee schedule,110% of humana physician fee schedule,265.61,150,,,fee schedule,100% of cms fee schedule,177.07,100,,,fee schedule,100% of cms physician fee schedule,265.61,150,,,fee schedule,150% of cms physician fee schedule,100,265.61,
ARTHROTOMY IP JOINT,,,981,RC,26080,HCPCS,outpatient,,,2503.75,1502.25,,,,,,other,not separately reimbusable,384.4,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,714.97,100,,,fee schedule,100% of cigna custom fee schedule,422.84,110,,,fee schedule,110% of cms physician fee schedule,388.24,101,,,fee schedule,101% of cms physician fee schedule ,388.24,116.15,,,fee schedule,116.51% of cms physician fee schedule,388.24,101,,,fee schedule,101% of cms physician fee schedule,730.36,110,,,fee schedule,110% of humana physician fee schedule,422.84,110,,,fee schedule,110% of humana physician fee schedule,576.6,150,,,fee schedule,100% of cms fee schedule,384.4,100,,,fee schedule,100% of cms physician fee schedule,576.6,150,,,fee schedule,150% of cms physician fee schedule,100,576.6,
TRMNT CLOSD IP JNT FX DIS,36010063,CDM,981,RC,26770,HCPCS,outpatient,,,289.88,173.93,,,,,,other,not separately reimbusable,259.1,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,463.58,100,,,fee schedule,100% of cigna custom fee schedule,285.01,110,,,fee schedule,110% of cms physician fee schedule,261.69,101,,,fee schedule,101% of cms physician fee schedule ,261.69,116.15,,,fee schedule,116.51% of cms physician fee schedule,261.69,101,,,fee schedule,101% of cms physician fee schedule,492.29,110,,,fee schedule,110% of humana physician fee schedule,285.01,110,,,fee schedule,110% of humana physician fee schedule,388.65,150,,,fee schedule,100% of cms fee schedule,259.1,100,,,fee schedule,100% of cms physician fee schedule,388.65,150,,,fee schedule,150% of cms physician fee schedule,100,388.65,
TRMT CLOSED MP JOINT DIS,36010088,CDM,981,RC,28630,HCPCS,outpatient,,,347.5,208.50,,,,,,other,not separately reimbusable,107.9,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,208.03,100,,,fee schedule,100% of cigna custom fee schedule,118.69,110,,,fee schedule,110% of cms physician fee schedule,108.98,101,,,fee schedule,101% of cms physician fee schedule ,108.98,116.15,,,fee schedule,116.51% of cms physician fee schedule,108.98,101,,,fee schedule,101% of cms physician fee schedule,205.01,110,,,fee schedule,110% of humana physician fee schedule,118.69,110,,,fee schedule,110% of humana physician fee schedule,161.85,150,,,fee schedule,100% of cms fee schedule,107.9,100,,,fee schedule,100% of cms physician fee schedule,161.85,150,,,fee schedule,150% of cms physician fee schedule,100,161.85,
APP CAST/SHORT ARM,36010133,CDM,981,RC,29075,HCPCS,outpatient,,,382.5,229.50,,,,,,other,not separately reimbusable,59.62,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,115.14,100,,,fee schedule,100% of cigna custom fee schedule,65.58,110,,,fee schedule,110% of cms physician fee schedule,60.22,101,,,fee schedule,101% of cms physician fee schedule ,60.22,116.15,,,fee schedule,116.51% of cms physician fee schedule,60.22,101,,,fee schedule,101% of cms physician fee schedule,113.28,110,,,fee schedule,110% of humana physician fee schedule,65.58,110,,,fee schedule,110% of humana physician fee schedule,89.43,150,,,fee schedule,100% of cms fee schedule,59.62,100,,,fee schedule,100% of cms physician fee schedule,89.43,150,,,fee schedule,150% of cms physician fee schedule,59.62,150,
APP LONG ARM SPLINT,36011049,CDM,981,RC,29105,HCPCS,outpatient,,,382.5,229.50,,,,,,other,not separately reimbusable,41.17,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,111.14,100,,,fee schedule,100% of cigna custom fee schedule,45.29,110,,,fee schedule,110% of cms physician fee schedule,41.58,101,,,fee schedule,101% of cms physician fee schedule ,41.58,116.15,,,fee schedule,116.51% of cms physician fee schedule,41.58,101,,,fee schedule,101% of cms physician fee schedule,78.22,110,,,fee schedule,110% of humana physician fee schedule,45.29,110,,,fee schedule,110% of humana physician fee schedule,61.76,150,,,fee schedule,100% of cms fee schedule,41.17,100,,,fee schedule,100% of cms physician fee schedule,61.76,150,,,fee schedule,150% of cms physician fee schedule,41.17,150,
APP SHORT ARM SPNT STATIC,36010311,CDM,981,RC,29125,HCPCS,outpatient,,,382.5,229.50,,,,,,other,not separately reimbusable,38.44,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,72.54,100,,,fee schedule,100% of cigna custom fee schedule,42.28,110,,,fee schedule,110% of cms physician fee schedule,38.82,101,,,fee schedule,101% of cms physician fee schedule ,38.82,116.15,,,fee schedule,116.51% of cms physician fee schedule,38.82,101,,,fee schedule,101% of cms physician fee schedule,73.04,110,,,fee schedule,110% of humana physician fee schedule,42.28,110,,,fee schedule,110% of humana physician fee schedule,57.66,150,,,fee schedule,100% of cms fee schedule,38.44,100,,,fee schedule,100% of cms physician fee schedule,57.66,150,,,fee schedule,150% of cms physician fee schedule,38.44,150,
APP  SHRT ARM SPLNT DYN,36011039,CDM,981,RC,29126,HCPCS,outpatient,,,142.5,85.50,,,,,,other,not separately reimbusable,47.14,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,89.21,100,,,fee schedule,100% of cigna custom fee schedule,51.85,110,,,fee schedule,110% of cms physician fee schedule,47.61,101,,,fee schedule,101% of cms physician fee schedule ,47.61,116.15,,,fee schedule,116.51% of cms physician fee schedule,47.61,101,,,fee schedule,101% of cms physician fee schedule,89.57,110,,,fee schedule,110% of humana physician fee schedule,51.85,110,,,fee schedule,110% of humana physician fee schedule,70.71,150,,,fee schedule,100% of cms fee schedule,47.14,100,,,fee schedule,100% of cms physician fee schedule,70.71,150,,,fee schedule,150% of cms physician fee schedule,47.14,150,
APP FINGER SPLINT STAT,36011044,CDM,981,RC,29130,HCPCS,outpatient,,,382.5,229.50,,,,,,other,not separately reimbusable,28.23,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,54.08,100,,,fee schedule,100% of cigna custom fee schedule,31.05,110,,,fee schedule,110% of cms physician fee schedule,28.51,101,,,fee schedule,101% of cms physician fee schedule ,28.51,116.15,,,fee schedule,116.51% of cms physician fee schedule,28.51,101,,,fee schedule,101% of cms physician fee schedule,53.64,110,,,fee schedule,110% of humana physician fee schedule,31.05,110,,,fee schedule,110% of humana physician fee schedule,42.35,150,,,fee schedule,100% of cms fee schedule,28.23,100,,,fee schedule,100% of cms physician fee schedule,42.35,150,,,fee schedule,150% of cms physician fee schedule,28.23,150,
APP LONG LEG SPLINT,36013008,CDM,981,RC,29505,HCPCS,outpatient,,,242.5,145.50,,,,,,other,not separately reimbusable,49.99,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,92.26,100,,,fee schedule,100% of cigna custom fee schedule,54.99,110,,,fee schedule,110% of cms physician fee schedule,50.49,101,,,fee schedule,101% of cms physician fee schedule ,50.49,116.15,,,fee schedule,116.51% of cms physician fee schedule,50.49,101,,,fee schedule,101% of cms physician fee schedule,94.98,110,,,fee schedule,110% of humana physician fee schedule,54.99,110,,,fee schedule,110% of humana physician fee schedule,74.99,150,,,fee schedule,100% of cms fee schedule,49.99,100,,,fee schedule,100% of cms physician fee schedule,74.99,150,,,fee schedule,150% of cms physician fee schedule,49.99,150,
APP SHORT LEG SPLINT,36011056,CDM,981,RC,29515,HCPCS,outpatient,,,242.5,145.50,,,,,,other,not separately reimbusable,47.73,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,92.56,100,,,fee schedule,100% of cigna custom fee schedule,52.5,110,,,fee schedule,110% of cms physician fee schedule,48.21,101,,,fee schedule,101% of cms physician fee schedule ,48.21,116.15,,,fee schedule,116.51% of cms physician fee schedule,48.21,101,,,fee schedule,101% of cms physician fee schedule,90.69,110,,,fee schedule,110% of humana physician fee schedule,52.5,110,,,fee schedule,110% of humana physician fee schedule,71.6,150,,,fee schedule,100% of cms fee schedule,47.73,100,,,fee schedule,100% of cms physician fee schedule,71.6,150,,,fee schedule,150% of cms physician fee schedule,47.73,150,
UNNA BOOT STRAPING physican charge,43601396,CDM,981,RC,29580,HCPCS,outpatient,,,74.56,44.74,,,,,,other,not separately reimbusable,25.63,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,66.37,100,,,fee schedule,100% of cigna custom fee schedule,28.19,110,,,fee schedule,110% of cms physician fee schedule,25.89,101,,,fee schedule,101% of cms physician fee schedule ,25.89,116.15,,,fee schedule,116.51% of cms physician fee schedule,25.89,101,,,fee schedule,101% of cms physician fee schedule,48.7,110,,,fee schedule,110% of humana physician fee schedule,28.19,110,,,fee schedule,110% of humana physician fee schedule,38.45,150,,,fee schedule,100% of cms fee schedule,25.63,100,,,fee schedule,100% of cms physician fee schedule,38.45,150,,,fee schedule,150% of cms physician fee schedule,25.63,150,
PHY FEE APPLY MULTLAY COMPRS LWR LEG,44500077,CDM,981,RC,29581,HCPCS,outpatient,,,25.96,15.58,,,,,,other,not separately reimbusable,25.6,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,24.13,100,,,fee schedule,100% of cigna custom fee schedule,28.16,110,,,fee schedule,110% of cms physician fee schedule,25.86,101,,,fee schedule,101% of cms physician fee schedule ,25.86,116.15,,,fee schedule,116.51% of cms physician fee schedule,25.86,101,,,fee schedule,101% of cms physician fee schedule,48.64,110,,,fee schedule,110% of humana physician fee schedule,28.16,110,,,fee schedule,110% of humana physician fee schedule,38.4,150,,,fee schedule,100% of cms fee schedule,25.6,100,,,fee schedule,100% of cms physician fee schedule,38.4,150,,,fee schedule,150% of cms physician fee schedule,25.6,150,
REMOVAL FB INTRANASAL,36010090,CDM,981,RC,30300,HCPCS,outpatient,,,353.75,212.25,,,,,,other,not separately reimbusable,114.4,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,189.9,100,,,fee schedule,100% of cigna custom fee schedule,125.84,110,,,fee schedule,110% of cms physician fee schedule,115.54,101,,,fee schedule,101% of cms physician fee schedule ,115.54,116.15,,,fee schedule,116.51% of cms physician fee schedule,115.54,101,,,fee schedule,101% of cms physician fee schedule,217.36,110,,,fee schedule,110% of humana physician fee schedule,125.84,110,,,fee schedule,110% of humana physician fee schedule,171.6,150,,,fee schedule,100% of cms fee schedule,114.4,100,,,fee schedule,100% of cms physician fee schedule,171.6,150,,,fee schedule,150% of cms physician fee schedule,100,171.6,
CONTROL NOSEBLEED ANT/SMP,36010091,CDM,981,RC,30901,HCPCS,outpatient,,,2583.39,1550.03,,,,,,other,not separately reimbusable,55.51,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,108.46,100,,,fee schedule,100% of cigna custom fee schedule,61.06,110,,,fee schedule,110% of cms physician fee schedule,56.07,101,,,fee schedule,101% of cms physician fee schedule ,56.07,116.15,,,fee schedule,116.51% of cms physician fee schedule,56.07,101,,,fee schedule,101% of cms physician fee schedule,105.47,110,,,fee schedule,110% of humana physician fee schedule,61.06,110,,,fee schedule,110% of humana physician fee schedule,83.27,150,,,fee schedule,100% of cms fee schedule,55.51,100,,,fee schedule,100% of cms physician fee schedule,83.27,150,,,fee schedule,150% of cms physician fee schedule,55.51,150,
INTUBATION ET,36010097,CDM,981,RC,31500,HCPCS,outpatient,,,1000,600.00,,,,,,other,not separately reimbusable,137.81,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,271.91,100,,,fee schedule,100% of cigna custom fee schedule,151.59,110,,,fee schedule,110% of cms physician fee schedule,139.19,101,,,fee schedule,101% of cms physician fee schedule ,139.19,116.15,,,fee schedule,116.51% of cms physician fee schedule,139.19,101,,,fee schedule,101% of cms physician fee schedule,261.84,110,,,fee schedule,110% of humana physician fee schedule,151.59,110,,,fee schedule,110% of humana physician fee schedule,206.72,150,,,fee schedule,100% of cms fee schedule,137.81,100,,,fee schedule,100% of cms physician fee schedule,206.72,150,,,fee schedule,150% of cms physician fee schedule,100,206.72,
CHEST TUBE PLACEMENT,36010098,CDM,981,RC,32551,HCPCS,outpatient,,,1305,783.00,,,,,,other,not separately reimbusable,151.11,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,282.43,100,,,fee schedule,100% of cigna custom fee schedule,166.22,110,,,fee schedule,110% of cms physician fee schedule,152.62,101,,,fee schedule,101% of cms physician fee schedule ,152.62,116.15,,,fee schedule,116.51% of cms physician fee schedule,152.62,101,,,fee schedule,101% of cms physician fee schedule,287.11,110,,,fee schedule,110% of humana physician fee schedule,166.22,110,,,fee schedule,110% of humana physician fee schedule,226.67,150,,,fee schedule,100% of cms fee schedule,151.11,100,,,fee schedule,100% of cms physician fee schedule,226.67,150,,,fee schedule,150% of cms physician fee schedule,100,226.67,
CENTRAL LINE PLACEMENT,,,981,RC,36011,HCPCS,outpatient,,,1250,750.00,,,,,,other,not separately reimbusable,150.27,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,282.9,100,,,fee schedule,100% of cigna custom fee schedule,165.3,110,,,fee schedule,110% of cms physician fee schedule,151.77,101,,,fee schedule,101% of cms physician fee schedule ,151.77,116.15,,,fee schedule,116.51% of cms physician fee schedule,151.77,101,,,fee schedule,101% of cms physician fee schedule,285.51,110,,,fee schedule,110% of humana physician fee schedule,165.3,110,,,fee schedule,110% of humana physician fee schedule,225.41,150,,,fee schedule,100% of cms fee schedule,150.27,100,,,fee schedule,100% of cms physician fee schedule,225.41,150,,,fee schedule,150% of cms physician fee schedule,100,225.41,
INSERT PICC CATH,36010102,CDM,981,RC,36556,HCPCS,outpatient,,,2887.5,1732.50,,,,,,other,not separately reimbusable,81.88,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,224.8,100,,,fee schedule,100% of cigna custom fee schedule,90.07,110,,,fee schedule,110% of cms physician fee schedule,82.7,101,,,fee schedule,101% of cms physician fee schedule ,82.7,116.15,,,fee schedule,116.51% of cms physician fee schedule,82.7,101,,,fee schedule,101% of cms physician fee schedule,155.57,110,,,fee schedule,110% of humana physician fee schedule,90.07,110,,,fee schedule,110% of humana physician fee schedule,122.82,150,,,fee schedule,100% of cms fee schedule,81.88,100,,,fee schedule,100% of cms physician fee schedule,122.82,150,,,fee schedule,150% of cms physician fee schedule,81.88,150,
BIOPSY OF LIP,,,981,RC,40490,HCPCS,outpatient,,,1095,657.00,,,,,,other,not separately reimbusable,66.26,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,139.27,100,,,fee schedule,100% of cigna custom fee schedule,72.89,110,,,fee schedule,110% of cms physician fee schedule,66.92,101,,,fee schedule,101% of cms physician fee schedule ,66.92,116.15,,,fee schedule,116.51% of cms physician fee schedule,66.92,101,,,fee schedule,101% of cms physician fee schedule,125.89,110,,,fee schedule,110% of humana physician fee schedule,72.89,110,,,fee schedule,110% of humana physician fee schedule,99.39,150,,,fee schedule,100% of cms fee schedule,66.26,100,,,fee schedule,100% of cms physician fee schedule,99.39,150,,,fee schedule,150% of cms physician fee schedule,66.26,150,
REP LAC MOUTH/2/3TNG 2.5<,36010300,CDM,981,RC,41250,HCPCS,outpatient,,,600,360.00,,,,,,other,not separately reimbusable,146.78,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,285.3,100,,,fee schedule,100% of cigna custom fee schedule,161.46,110,,,fee schedule,110% of cms physician fee schedule,148.25,101,,,fee schedule,101% of cms physician fee schedule ,148.25,116.15,,,fee schedule,116.51% of cms physician fee schedule,148.25,101,,,fee schedule,101% of cms physician fee schedule,278.88,110,,,fee schedule,110% of humana physician fee schedule,161.46,110,,,fee schedule,110% of humana physician fee schedule,220.17,150,,,fee schedule,100% of cms fee schedule,146.78,100,,,fee schedule,100% of cms physician fee schedule,220.17,150,,,fee schedule,150% of cms physician fee schedule,100,220.17,
INC THROMB HEMORRHOID EXT,36010187,CDM,981,RC,46083,HCPCS,outpatient,,,322.5,193.50,,,,,,other,not separately reimbusable,105.49,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,192.44,100,,,fee schedule,100% of cigna custom fee schedule,116.04,110,,,fee schedule,110% of cms physician fee schedule,106.54,101,,,fee schedule,101% of cms physician fee schedule ,106.54,116.15,,,fee schedule,116.51% of cms physician fee schedule,106.54,101,,,fee schedule,101% of cms physician fee schedule,200.43,110,,,fee schedule,110% of humana physician fee schedule,116.04,110,,,fee schedule,110% of humana physician fee schedule,158.24,150,,,fee schedule,100% of cms fee schedule,105.49,100,,,fee schedule,100% of cms physician fee schedule,158.24,150,,,fee schedule,150% of cms physician fee schedule,100,158.24,
INSERT TEMP INDWLN CATH,36011020,CDM,981,RC,51702,HCPCS,outpatient,,,382.5,229.50,,,,,,other,not separately reimbusable,24.46,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,39.39,100,,,fee schedule,100% of cigna custom fee schedule,26.91,110,,,fee schedule,110% of cms physician fee schedule,24.7,101,,,fee schedule,101% of cms physician fee schedule ,24.7,116.15,,,fee schedule,116.51% of cms physician fee schedule,24.7,101,,,fee schedule,101% of cms physician fee schedule,46.47,110,,,fee schedule,110% of humana physician fee schedule,26.91,110,,,fee schedule,110% of humana physician fee schedule,36.69,150,,,fee schedule,100% of cms fee schedule,24.46,100,,,fee schedule,100% of cms physician fee schedule,36.69,150,,,fee schedule,150% of cms physician fee schedule,24.46,150,
I&D SCROTAL,43601687,CDM,981,RC,54700,HCPCS,outpatient,,,347.5,208.50,,,,,,other,not separately reimbusable,205.43,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,323.19,100,,,fee schedule,100% of cigna custom fee schedule,225.97,110,,,fee schedule,110% of cms physician fee schedule,207.48,101,,,fee schedule,101% of cms physician fee schedule ,207.48,116.15,,,fee schedule,116.51% of cms physician fee schedule,207.48,101,,,fee schedule,101% of cms physician fee schedule,390.32,110,,,fee schedule,110% of humana physician fee schedule,225.97,110,,,fee schedule,110% of humana physician fee schedule,308.15,150,,,fee schedule,100% of cms fee schedule,205.43,100,,,fee schedule,100% of cms physician fee schedule,308.15,150,,,fee schedule,150% of cms physician fee schedule,100,308.15,
DRESS/DEBRID P-THICK BURN L,36010028,CDM,981,RC,16030,HCPCS,outpatient,,,284.34,170.60,,,,,,other,not separately reimbusable,127.51,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,244.26,100,,,fee schedule,100% of cigna custom fee schedule,140.26,110,,,fee schedule,110% of cms physician fee schedule,128.79,101,,,fee schedule,101% of cms physician fee schedule ,128.79,116.15,,,fee schedule,116.51% of cms physician fee schedule,128.79,101,,,fee schedule,101% of cms physician fee schedule,242.27,110,,,fee schedule,110% of humana physician fee schedule,140.26,110,,,fee schedule,110% of humana physician fee schedule,191.27,150,,,fee schedule,100% of cms fee schedule,127.51,100,,,fee schedule,100% of cms physician fee schedule,191.27,150,,,fee schedule,150% of cms physician fee schedule,100,191.27,
I&D PERINEAL/VULVA ABSCES,36010225,CDM,981,RC,56405,HCPCS,outpatient,,,406.25,243.75,,,,,,other,not separately reimbusable,120.64,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,211.51,100,,,fee schedule,100% of cigna custom fee schedule,132.7,110,,,fee schedule,110% of cms physician fee schedule,121.85,101,,,fee schedule,101% of cms physician fee schedule ,121.85,116.15,,,fee schedule,116.51% of cms physician fee schedule,121.85,101,,,fee schedule,101% of cms physician fee schedule,229.22,110,,,fee schedule,110% of humana physician fee schedule,132.7,110,,,fee schedule,110% of humana physician fee schedule,180.96,150,,,fee schedule,100% of cms fee schedule,120.64,100,,,fee schedule,100% of cms physician fee schedule,180.96,150,,,fee schedule,150% of cms physician fee schedule,100,180.96,
SPINAL PUNCTURE LUMBAR DX,36009170,CDM,981,RC,62270,HCPCS,outpatient,,,375,225.00,,,,,,other,not separately reimbusable,62.84,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,132.48,100,,,fee schedule,100% of cigna custom fee schedule,69.12,110,,,fee schedule,110% of cms physician fee schedule,63.47,101,,,fee schedule,101% of cms physician fee schedule ,63.47,116.15,,,fee schedule,116.51% of cms physician fee schedule,63.47,101,,,fee schedule,101% of cms physician fee schedule,119.4,110,,,fee schedule,110% of humana physician fee schedule,69.12,110,,,fee schedule,110% of humana physician fee schedule,94.26,150,,,fee schedule,100% of cms fee schedule,62.84,100,,,fee schedule,100% of cms physician fee schedule,94.26,150,,,fee schedule,150% of cms physician fee schedule,62.84,150,
"RMVL FB EXT EYE CONJ,SMPL",36010108,CDM,981,RC,65205,HCPCS,outpatient,,,557.5,334.50,,,,,,other,not separately reimbusable,27.36,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,51.32,100,,,fee schedule,100% of cigna custom fee schedule,30.1,110,,,fee schedule,110% of cms physician fee schedule,27.63,101,,,fee schedule,101% of cms physician fee schedule ,27.63,116.15,,,fee schedule,116.51% of cms physician fee schedule,27.63,101,,,fee schedule,101% of cms physician fee schedule,51.98,110,,,fee schedule,110% of humana physician fee schedule,30.1,110,,,fee schedule,110% of humana physician fee schedule,41.04,150,,,fee schedule,100% of cms fee schedule,27.36,100,,,fee schedule,100% of cms physician fee schedule,41.04,150,,,fee schedule,150% of cms physician fee schedule,27.36,150,
"RMVL FB CORNE,W/O SLT LMP",36010109,CDM,981,RC,65220,HCPCS,outpatient,,,209,125.40,,,,,,other,not separately reimbusable,39.6,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,50.34,100,,,fee schedule,100% of cigna custom fee schedule,43.56,110,,,fee schedule,110% of cms physician fee schedule,40,101,,,fee schedule,101% of cms physician fee schedule ,40,116.15,,,fee schedule,116.51% of cms physician fee schedule,40,101,,,fee schedule,101% of cms physician fee schedule,75.24,110,,,fee schedule,110% of humana physician fee schedule,43.56,110,,,fee schedule,110% of humana physician fee schedule,59.4,150,,,fee schedule,100% of cms fee schedule,39.6,100,,,fee schedule,100% of cms physician fee schedule,59.4,150,,,fee schedule,150% of cms physician fee schedule,39.6,150,
BLEPHAROTOMY,36010272,CDM,981,RC,67700,HCPCS,outpatient,,,350,210.00,,,,,,other,not separately reimbusable,107.94,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,133.25,100,,,fee schedule,100% of cigna custom fee schedule,118.73,110,,,fee schedule,110% of cms physician fee schedule,109.02,101,,,fee schedule,101% of cms physician fee schedule ,109.02,116.15,,,fee schedule,116.51% of cms physician fee schedule,109.02,101,,,fee schedule,101% of cms physician fee schedule,205.09,110,,,fee schedule,110% of humana physician fee schedule,118.73,110,,,fee schedule,110% of humana physician fee schedule,161.91,150,,,fee schedule,100% of cms fee schedule,107.94,100,,,fee schedule,100% of cms physician fee schedule,161.91,150,,,fee schedule,150% of cms physician fee schedule,100,161.91,
SUBCONJUNCTIVAL INJECTION,,,981,RC,68200,HCPCS,outpatient,,,207.5,124.50,,,,,,other,not separately reimbusable,31.83,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,40.41,100,,,fee schedule,100% of cigna custom fee schedule,35.01,110,,,fee schedule,110% of cms physician fee schedule,32.15,101,,,fee schedule,101% of cms physician fee schedule ,32.15,116.15,,,fee schedule,116.51% of cms physician fee schedule,32.15,101,,,fee schedule,101% of cms physician fee schedule,60.48,110,,,fee schedule,110% of humana physician fee schedule,35.01,110,,,fee schedule,110% of humana physician fee schedule,47.75,150,,,fee schedule,100% of cms fee schedule,31.83,100,,,fee schedule,100% of cms physician fee schedule,47.75,150,,,fee schedule,150% of cms physician fee schedule,31.83,150,
I&D EXT EAR ABSCESS;SMPL,36010205,CDM,981,RC,69000,HCPCS,outpatient,,,187.5,112.50,,,,,,other,not separately reimbusable,119.05,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,217.21,100,,,fee schedule,100% of cigna custom fee schedule,130.96,110,,,fee schedule,110% of cms physician fee schedule,120.24,101,,,fee schedule,101% of cms physician fee schedule ,120.24,116.15,,,fee schedule,116.51% of cms physician fee schedule,120.24,101,,,fee schedule,101% of cms physician fee schedule,226.2,110,,,fee schedule,110% of humana physician fee schedule,130.96,110,,,fee schedule,110% of humana physician fee schedule,178.58,150,,,fee schedule,100% of cms fee schedule,119.05,100,,,fee schedule,100% of cms physician fee schedule,178.58,150,,,fee schedule,150% of cms physician fee schedule,100,178.58,
BIOPSY EXTERNAL EAR,,,981,RC,69100,HCPCS,outpatient,,,375,225.00,,,,,,other,not separately reimbusable,44.38,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,92.16,100,,,fee schedule,100% of cigna custom fee schedule,48.82,110,,,fee schedule,110% of cms physician fee schedule,44.82,101,,,fee schedule,101% of cms physician fee schedule ,44.82,116.15,,,fee schedule,116.51% of cms physician fee schedule,44.82,101,,,fee schedule,101% of cms physician fee schedule,84.32,110,,,fee schedule,110% of humana physician fee schedule,48.82,110,,,fee schedule,110% of humana physician fee schedule,66.57,150,,,fee schedule,100% of cms fee schedule,44.38,100,,,fee schedule,100% of cms physician fee schedule,66.57,150,,,fee schedule,150% of cms physician fee schedule,44.38,150,
RMVL FB EXTRNL AUD CANAL,36010127,CDM,981,RC,69200,HCPCS,outpatient,,,190,114.00,,,,,,other,not separately reimbusable,45.56,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,88.67,100,,,fee schedule,100% of cigna custom fee schedule,50.12,110,,,fee schedule,110% of cms physician fee schedule,46.02,101,,,fee schedule,101% of cms physician fee schedule ,46.02,116.15,,,fee schedule,116.51% of cms physician fee schedule,46.02,101,,,fee schedule,101% of cms physician fee schedule,86.56,110,,,fee schedule,110% of humana physician fee schedule,50.12,110,,,fee schedule,110% of humana physician fee schedule,68.34,150,,,fee schedule,100% of cms fee schedule,45.56,100,,,fee schedule,100% of cms physician fee schedule,68.34,150,,,fee schedule,150% of cms physician fee schedule,45.56,150,
REM IMPACT CERUMEN UNILAT,36010128,CDM,981,RC,69210,HCPCS,outpatient,,,75,45.00,,,,,,other,not separately reimbusable,31.51,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,61.9,100,,,fee schedule,100% of cigna custom fee schedule,34.66,110,,,fee schedule,110% of cms physician fee schedule,31.83,101,,,fee schedule,101% of cms physician fee schedule ,31.83,116.15,,,fee schedule,116.51% of cms physician fee schedule,31.83,101,,,fee schedule,101% of cms physician fee schedule,59.87,110,,,fee schedule,110% of humana physician fee schedule,34.66,110,,,fee schedule,110% of humana physician fee schedule,47.27,150,,,fee schedule,100% of cms fee schedule,31.51,100,,,fee schedule,100% of cms physician fee schedule,47.27,150,,,fee schedule,150% of cms physician fee schedule,31.51,150,
CARDIOVERSION,35000029,CDM,981,RC,92960,HCPCS,outpatient,,,1000,600.00,,,,,,other,not separately reimbusable,102.32,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,223.69,100,,,fee schedule,100% of cigna custom fee schedule,112.55,110,,,fee schedule,110% of cms physician fee schedule,103.34,101,,,fee schedule,101% of cms physician fee schedule ,103.34,116.15,,,fee schedule,116.51% of cms physician fee schedule,103.34,101,,,fee schedule,101% of cms physician fee schedule,194.41,110,,,fee schedule,110% of humana physician fee schedule,112.55,110,,,fee schedule,110% of humana physician fee schedule,153.48,150,,,fee schedule,100% of cms fee schedule,102.32,100,,,fee schedule,100% of cms physician fee schedule,153.48,150,,,fee schedule,150% of cms physician fee schedule,100,153.48,
VENT MGMT INPAT INIAL DAY,43102010,CDM,410,RC,94002,HCPCS,outpatient,,,287.5,172.50,,172.5,60,,138,percent of total billed charges,60% of total billed charges,138,48,,110.4,percent of total billed charges,48% of total billed charges,293.41,100,,,fee schedule,100% of bcbs custom fee schedule,293.41,100,,,fee schedule,100% of bcbs custom fee schedule,325.69,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,201.25,70,,161,percent of total billed charges,70% of total billed charges,139.38,48.48,,111.504,percent of total billed charges,48.48% of total billed charges,102.64,116.15,,,fee schedule,116.51% of cms physician fee schedule,139.38,48.48,,111.504,percent of total billed charges,48.48% of total billed charges,201.25,70,,161,percent of total billed charges,70% of total billed charges,201.25,70,,161,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,139.38,48.48,,111.504,percent of total billed charges,48.48% of total billed charges,258.75,90,,207,percent of total billed charges,90% of total billed charges,48.48,258.75,
DEBRIDEMENT SELECT< 20 CM,36000015,CDM,981,RC,97597,HCPCS,outpatient,,,47.7,28.62,,,,,,other,not separately reimbusable,34.33,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,12.82,100,,,fee schedule,100% of cigna custom fee schedule,65.23,110,,,fee schedule,110% of cms physician fee schedule,34.67,101,,,fee schedule,101% of cms physician fee schedule ,34.67,116.15,,,fee schedule,116.51% of cms physician fee schedule,34.67,101,,,fee schedule,101% of cms physician fee schedule,27.46,80,,,fee schedule,80% of humana physician fee schedule,27.46,110,,,fee schedule,110% of humana physician fee schedule,51.5,150,,,fee schedule,100% of cms fee schedule,34.33,100,,,fee schedule,100% of cms physician fee schedule,51.5,150,,,fee schedule,150% of cms physician fee schedule,34.33,150,
OUTPT VISIT LEVEL 2 PHY,43600141,CDM,982,RC,99212,HCPCS,outpatient,,,52.46,31.48,,,,,,other,not separately reimbusable,34.04,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,24.81,100,,,fee schedule,100% of cigna custom fee schedule,37.44,110,,,fee schedule,110% of cms physician fee schedule,34.38,101,,,fee schedule,101% of cms physician fee schedule ,34.38,116.15,,,fee schedule,116.51% of cms physician fee schedule,34.38,101,,,fee schedule,101% of cms physician fee schedule,64.68,110,,,fee schedule,110% of humana physician fee schedule,37.44,110,,,fee schedule,110% of humana physician fee schedule,51.06,150,,,fee schedule,100% of cms fee schedule,34.04,100,,,fee schedule,100% of cms physician fee schedule,51.06,150,,,fee schedule,150% of cms physician fee schedule,34.04,150,
OUTPT VISIT LEVEL 3 PHY,43600142,CDM,982,RC,99213,HCPCS,outpatient,,,104.66,62.80,,,,,,other,not separately reimbusable,63.41,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,49.55,100,,,fee schedule,100% of cigna custom fee schedule,69.75,110,,,fee schedule,110% of cms physician fee schedule,64.04,101,,,fee schedule,101% of cms physician fee schedule ,64.04,116.15,,,fee schedule,116.51% of cms physician fee schedule,64.04,101,,,fee schedule,101% of cms physician fee schedule,120.48,110,,,fee schedule,110% of humana physician fee schedule,69.75,110,,,fee schedule,110% of humana physician fee schedule,95.12,150,,,fee schedule,100% of cms fee schedule,63.41,100,,,fee schedule,100% of cms physician fee schedule,95.12,150,,,fee schedule,150% of cms physician fee schedule,63.41,150,
OUTPT VISIT LEVEL 4 PHY,43600143,CDM,982,RC,99214,HCPCS,outpatient,,,226.72,136.03,,,,,,other,not separately reimbusable,93.44,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,76.33,100,,,fee schedule,100% of cigna custom fee schedule,102.78,110,,,fee schedule,110% of cms physician fee schedule,94.37,101,,,fee schedule,101% of cms physician fee schedule ,94.37,116.15,,,fee schedule,116.51% of cms physician fee schedule,94.37,101,,,fee schedule,101% of cms physician fee schedule,177.54,110,,,fee schedule,110% of humana physician fee schedule,102.78,110,,,fee schedule,110% of humana physician fee schedule,140.16,150,,,fee schedule,100% of cms fee schedule,93.44,100,,,fee schedule,100% of cms physician fee schedule,140.16,150,,,fee schedule,150% of cms physician fee schedule,93.44,150,
OUTPT VISIT LEVEL 5 PHY,43600144,CDM,982,RC,99215,HCPCS,outpatient,,,358.58,215.15,,,,,,other,not separately reimbusable,138.61,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,108,100,,,fee schedule,100% of cigna custom fee schedule,152.47,110,,,fee schedule,110% of cms physician fee schedule,140,101,,,fee schedule,101% of cms physician fee schedule ,140,116.15,,,fee schedule,116.51% of cms physician fee schedule,140,101,,,fee schedule,101% of cms physician fee schedule,263.36,110,,,fee schedule,110% of humana physician fee schedule,152.47,110,,,fee schedule,110% of humana physician fee schedule,207.92,150,,,fee schedule,100% of cms fee schedule,138.61,100,,,fee schedule,100% of cms physician fee schedule,207.92,150,,,fee schedule,150% of cms physician fee schedule,100,207.92,
MINIMAL OUT PT VISIT,32000200,CDM,981,RC,99211,HCPCS,outpatient,,,18.82,11.29,,,,,,other,not separately reimbusable,8.41,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,8.94,100,,,fee schedule,100% of cigna custom fee schedule,9.25,110,,,fee schedule,110% of cms physician fee schedule,8.49,101,,,fee schedule,101% of cms physician fee schedule ,8.49,116.15,,,fee schedule,116.51% of cms physician fee schedule,8.49,101,,,fee schedule,101% of cms physician fee schedule,15.98,110,,,fee schedule,110% of humana physician fee schedule,9.25,110,,,fee schedule,110% of humana physician fee schedule,12.62,150,,,fee schedule,100% of cms fee schedule,8.41,100,,,fee schedule,100% of cms physician fee schedule,12.62,150,,,fee schedule,150% of cms physician fee schedule,8.41,150,
CRITICAL CARE 30-74 MIN,32009062,CDM,981,RC,99291,HCPCS,outpatient,,,803.75,482.25,,,,,,other,not separately reimbusable,206.31,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,219.37,100,,,fee schedule,100% of cigna custom fee schedule,226.94,110,,,fee schedule,110% of cms physician fee schedule,208.37,101,,,fee schedule,101% of cms physician fee schedule ,208.37,116.15,,,fee schedule,116.51% of cms physician fee schedule,208.37,101,,,fee schedule,101% of cms physician fee schedule,391.99,110,,,fee schedule,110% of humana physician fee schedule,226.94,110,,,fee schedule,110% of humana physician fee schedule,309.47,150,,,fee schedule,100% of cms fee schedule,206.31,100,,,fee schedule,100% of cms physician fee schedule,309.47,150,,,fee schedule,150% of cms physician fee schedule,100,309.47,
CRITICAL CARE ADD 30 MIN,32009063,CDM,981,RC,99292,HCPCS,outpatient,,,261.25,156.75,,,,,,other,not separately reimbusable,104.06,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,110.05,100,,,fee schedule,100% of cigna custom fee schedule,114.47,110,,,fee schedule,110% of cms physician fee schedule,105.1,101,,,fee schedule,101% of cms physician fee schedule ,105.1,116.15,,,fee schedule,116.51% of cms physician fee schedule,105.1,101,,,fee schedule,101% of cms physician fee schedule,197.71,110,,,fee schedule,110% of humana physician fee schedule,114.47,110,,,fee schedule,110% of humana physician fee schedule,156.09,150,,,fee schedule,100% of cms fee schedule,104.06,100,,,fee schedule,100% of cms physician fee schedule,156.09,150,,,fee schedule,150% of cms physician fee schedule,100,156.09,
Complex Repair Phys - Integumentary,36010193,CDM,981,RC,13133,HCPCS,outpatient,,,377.5,226.50,,,,,,other,not separately reimbusable,120.1,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,242.56,100,,,fee schedule,100% of cigna custom fee schedule,132.11,110,,,fee schedule,110% of cms physician fee schedule,121.3,101,,,fee schedule,101% of cms physician fee schedule ,121.3,116.15,,,fee schedule,116.51% of cms physician fee schedule,121.3,101,,,fee schedule,101% of cms physician fee schedule,228.19,110,,,fee schedule,110% of humana physician fee schedule,132.11,110,,,fee schedule,110% of humana physician fee schedule,180.15,150,,,fee schedule,100% of cms fee schedule,120.1,100,,,fee schedule,100% of cms physician fee schedule,180.15,150,,,fee schedule,150% of cms physician fee schedule,100,180.15,
CMPLX RPR F/C/C/M/N/AX/G/H/F;2.6-7.5,36010186,CDM,981,RC,13132,HCPCS,outpatient,,,510.66,306.40,,,,,,other,not separately reimbusable,287.07,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,574.52,100,,,fee schedule,100% of cigna custom fee schedule,315.78,110,,,fee schedule,110% of cms physician fee schedule,289.94,101,,,fee schedule,101% of cms physician fee schedule ,289.94,116.15,,,fee schedule,116.51% of cms physician fee schedule,289.94,101,,,fee schedule,101% of cms physician fee schedule,545.43,110,,,fee schedule,110% of humana physician fee schedule,315.78,110,,,fee schedule,110% of humana physician fee schedule,430.61,150,,,fee schedule,100% of cms fee schedule,287.07,100,,,fee schedule,100% of cms physician fee schedule,430.61,150,,,fee schedule,150% of cms physician fee schedule,100,430.61,
CMPLX REPR S/A/L;2.6-7.5,36010134,CDM,981,RC,13121,HCPCS,outpatient,,,826.25,495.75,,,,,,other,not separately reimbusable,244.65,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,487.03,100,,,fee schedule,100% of cigna custom fee schedule,269.12,110,,,fee schedule,110% of cms physician fee schedule,247.1,101,,,fee schedule,101% of cms physician fee schedule ,247.1,116.15,,,fee schedule,116.51% of cms physician fee schedule,247.1,101,,,fee schedule,101% of cms physician fee schedule,464.84,110,,,fee schedule,110% of humana physician fee schedule,269.12,110,,,fee schedule,110% of humana physician fee schedule,366.98,150,,,fee schedule,100% of cms fee schedule,244.65,100,,,fee schedule,100% of cms physician fee schedule,366.98,150,,,fee schedule,150% of cms physician fee schedule,100,366.98,
CMPLX REP F/G/H/F;1.1-2.5,36010136,CDM,981,RC,13131,HCPCS,outpatient,,,377.5,226.50,,,,,,other,not separately reimbusable,229.74,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,455.42,100,,,fee schedule,100% of cigna custom fee schedule,252.71,110,,,fee schedule,110% of cms physician fee schedule,232.04,101,,,fee schedule,101% of cms physician fee schedule ,232.04,116.15,,,fee schedule,116.51% of cms physician fee schedule,232.04,101,,,fee schedule,101% of cms physician fee schedule,436.51,110,,,fee schedule,110% of humana physician fee schedule,252.71,110,,,fee schedule,110% of humana physician fee schedule,344.61,150,,,fee schedule,100% of cms fee schedule,229.74,100,,,fee schedule,100% of cms physician fee schedule,344.61,150,,,fee schedule,150% of cms physician fee schedule,100,344.61,
DESTR PREMAL LES 2-14 LES,43600290,CDM,981,RC,17003,HCPCS,outpatient,,,100,60.00,,,,,,other,not separately reimbusable,1.91,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,2.93,100,,,fee schedule,100% of cigna custom fee schedule,2.1,110,,,fee schedule,110% of cms physician fee schedule,1.93,101,,,fee schedule,101% of cms physician fee schedule ,1.93,116.15,,,fee schedule,116.51% of cms physician fee schedule,1.93,101,,,fee schedule,101% of cms physician fee schedule,3.63,110,,,fee schedule,110% of humana physician fee schedule,2.1,110,,,fee schedule,110% of humana physician fee schedule,2.87,150,,,fee schedule,100% of cms fee schedule,1.91,100,,,fee schedule,100% of cms physician fee schedule,2.87,150,,,fee schedule,150% of cms physician fee schedule,1.91,150,
DEBRIDE SKIN & SQ TISSUE,36010007,CDM,981,RC,11042,HCPCS,outpatient,,,129.4,77.64,,,,,,other,not separately reimbusable,58.1,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,72.3,100,,,fee schedule,100% of cigna custom fee schedule,63.91,110,,,fee schedule,110% of cms physician fee schedule,58.68,101,,,fee schedule,101% of cms physician fee schedule ,58.68,116.15,,,fee schedule,116.51% of cms physician fee schedule,58.68,101,,,fee schedule,101% of cms physician fee schedule,110.39,110,,,fee schedule,110% of humana physician fee schedule,63.91,110,,,fee schedule,110% of humana physician fee schedule,87.15,150,,,fee schedule,100% of cms fee schedule,58.1,100,,,fee schedule,100% of cms physician fee schedule,87.15,150,,,fee schedule,150% of cms physician fee schedule,58.1,150,
FLU ADMINISTRATION,32009069,CDM,771,RC,G0008,HCPCS,outpatient,,,40,24.00,,24,60,,19.2,percent of total billed charges,60% of total billed charges,19.2,48,,15.36,percent of total billed charges,48% of total billed charges,20,50,,16,percent of total billed charges,50% of total billed charges,20,50,,16,percent of total billed charges,50% of total billed charges,20,50,,16,percent of total billed charges,50% of total billed charges,20,50,,16,percent of total billed charges,50% of total billed charges,28,70,,22.4,percent of total billed charges,70% of total billed charges,19.39,48.48,,15.512,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,19.39,48.48,,15.512,percent of total billed charges,48.48% of total billed charges,28,70,,22.4,percent of total billed charges,70% of total billed charges,28,70,,22.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,19.39,48.48,,15.512,percent of total billed charges,48.48% of total billed charges,36,90,,28.8,percent of total billed charges,90% of total billed charges,19.39,90,
DRAINAGE OF SCROTAL ABCESS,36010190,CDM,982,RC,55100,HCPCS,outpatient,,,182.34,109.40,,,,,,other,not separately reimbusable,161.16,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,248.41,100,,,fee schedule,100% of cigna custom fee schedule,177.28,110,,,fee schedule,110% of cms physician fee schedule,162.77,101,,,fee schedule,101% of cms physician fee schedule ,162.77,116.15,,,fee schedule,116.51% of cms physician fee schedule,162.77,101,,,fee schedule,101% of cms physician fee schedule,306.2,110,,,fee schedule,110% of humana physician fee schedule,177.28,110,,,fee schedule,110% of humana physician fee schedule,241.74,150,,,fee schedule,100% of cms fee schedule,161.16,100,,,fee schedule,100% of cms physician fee schedule,241.74,150,,,fee schedule,150% of cms physician fee schedule,100,241.74,
FINE NEEDLE ASPIRATION PHY FEE,36011040,CDM,982,RC,10021,HCPCS,outpatient,,,181.92,109.15,,,,,,other,not separately reimbusable,53.03,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,128.04,100,,,fee schedule,100% of cigna custom fee schedule,58.33,110,,,fee schedule,110% of cms physician fee schedule,53.56,101,,,fee schedule,101% of cms physician fee schedule ,53.56,116.15,,,fee schedule,116.51% of cms physician fee schedule,53.56,101,,,fee schedule,101% of cms physician fee schedule,100.76,110,,,fee schedule,110% of humana physician fee schedule,58.33,110,,,fee schedule,110% of humana physician fee schedule,79.55,150,,,fee schedule,100% of cms fee schedule,53.03,100,,,fee schedule,100% of cms physician fee schedule,79.55,150,,,fee schedule,150% of cms physician fee schedule,53.03,150,
PHY CHRG EXCI OF NAILFOLD,36013011,CDM,982,RC,11765,HCPCS,outpatient,,,107.5,64.50,,,,,,other,not separately reimbusable,87.57,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,165.79,100,,,fee schedule,100% of cigna custom fee schedule,96.33,110,,,fee schedule,110% of cms physician fee schedule,88.45,101,,,fee schedule,101% of cms physician fee schedule ,88.45,116.15,,,fee schedule,116.51% of cms physician fee schedule,88.45,101,,,fee schedule,101% of cms physician fee schedule,166.38,110,,,fee schedule,110% of humana physician fee schedule,96.33,110,,,fee schedule,110% of humana physician fee schedule,131.36,150,,,fee schedule,100% of cms fee schedule,87.57,100,,,fee schedule,100% of cms physician fee schedule,131.36,150,,,fee schedule,150% of cms physician fee schedule,87.57,150,
REPAIR INTERMEDIATE S/A/T/E 7.6-12.5 CM,36010020,CDM,981,RC,12034,HCPCS,outpatient,,,346.84,208.10,,,,,,other,not separately reimbusable,195.16,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,376.18,100,,,fee schedule,100% of cigna custom fee schedule,214.68,110,,,fee schedule,110% of cms physician fee schedule,197.11,101,,,fee schedule,101% of cms physician fee schedule ,197.11,116.15,,,fee schedule,116.51% of cms physician fee schedule,197.11,101,,,fee schedule,101% of cms physician fee schedule,370.8,110,,,fee schedule,110% of humana physician fee schedule,214.68,110,,,fee schedule,110% of humana physician fee schedule,292.74,150,,,fee schedule,100% of cms fee schedule,195.16,100,,,fee schedule,100% of cms physician fee schedule,292.74,150,,,fee schedule,150% of cms physician fee schedule,100,292.74,
INIT HOSP CARE ADM 40 MIN,43710006,CDM,987,RC,99221,HCPCS,outpatient,,,227.5,136.50,,,,,,other,not separately reimbusable,80.06,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,99.27,100,,,fee schedule,100% of cigna custom fee schedule,88.07,110,,,fee schedule,110% of cms physician fee schedule,80.86,101,,,fee schedule,101% of cms physician fee schedule ,80.86,116.15,,,fee schedule,116.51% of cms physician fee schedule,80.86,101,,,fee schedule,101% of cms physician fee schedule,152.11,110,,,fee schedule,110% of humana physician fee schedule,88.07,110,,,fee schedule,110% of humana physician fee schedule,120.09,150,,,fee schedule,100% of cms fee schedule,80.06,100,,,fee schedule,100% of cms physician fee schedule,120.09,150,,,fee schedule,150% of cms physician fee schedule,80.06,150,
INIT HOSP CARE ADM 55 MIN,43710007,CDM,987,RC,99222,HCPCS,outpatient,,,305,183.00,,,,,,other,not separately reimbusable,125.92,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,133.43,100,,,fee schedule,100% of cigna custom fee schedule,138.51,110,,,fee schedule,110% of cms physician fee schedule,127.18,101,,,fee schedule,101% of cms physician fee schedule ,127.18,116.15,,,fee schedule,116.51% of cms physician fee schedule,127.18,101,,,fee schedule,101% of cms physician fee schedule,239.25,110,,,fee schedule,110% of humana physician fee schedule,138.51,110,,,fee schedule,110% of humana physician fee schedule,188.88,150,,,fee schedule,100% of cms fee schedule,125.92,100,,,fee schedule,100% of cms physician fee schedule,188.88,150,,,fee schedule,150% of cms physician fee schedule,100,188.88,
INIT HOSP CARE ADM 75 MIN,43710008,CDM,987,RC,99223,HCPCS,outpatient,,,392.5,235.50,,,,,,other,not separately reimbusable,166.64,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,197.31,100,,,fee schedule,100% of cigna custom fee schedule,183.3,110,,,fee schedule,110% of cms physician fee schedule,168.31,101,,,fee schedule,101% of cms physician fee schedule ,168.31,116.15,,,fee schedule,116.51% of cms physician fee schedule,168.31,101,,,fee schedule,101% of cms physician fee schedule,316.62,110,,,fee schedule,110% of humana physician fee schedule,183.3,110,,,fee schedule,110% of humana physician fee schedule,249.96,150,,,fee schedule,100% of cms fee schedule,166.64,100,,,fee schedule,100% of cms physician fee schedule,249.96,150,,,fee schedule,150% of cms physician fee schedule,100,249.96,
SUBS HOSP CARE LOW 25 MIN,32009059,CDM,987,RC,99231,HCPCS,outpatient,,,113.75,68.25,,,,,,other,not separately reimbusable,47.79,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,38.31,100,,,fee schedule,100% of cigna custom fee schedule,52.57,110,,,fee schedule,110% of cms physician fee schedule,48.27,101,,,fee schedule,101% of cms physician fee schedule ,48.27,116.15,,,fee schedule,116.51% of cms physician fee schedule,48.27,101,,,fee schedule,101% of cms physician fee schedule,90.8,110,,,fee schedule,110% of humana physician fee schedule,52.57,110,,,fee schedule,110% of humana physician fee schedule,71.69,150,,,fee schedule,100% of cms fee schedule,47.79,100,,,fee schedule,100% of cms physician fee schedule,71.69,150,,,fee schedule,150% of cms physician fee schedule,47.79,150,
SUBS HOSP CARE MOD 35 MIN,32009060,CDM,987,RC,99232,HCPCS,outpatient,,,156.25,93.75,,,,,,other,not separately reimbusable,75.86,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,70.16,100,,,fee schedule,100% of cigna custom fee schedule,83.45,110,,,fee schedule,110% of cms physician fee schedule,76.62,101,,,fee schedule,101% of cms physician fee schedule ,76.62,116.15,,,fee schedule,116.51% of cms physician fee schedule,76.62,101,,,fee schedule,101% of cms physician fee schedule,144.13,110,,,fee schedule,110% of humana physician fee schedule,83.45,110,,,fee schedule,110% of humana physician fee schedule,113.79,150,,,fee schedule,100% of cms fee schedule,75.86,100,,,fee schedule,100% of cms physician fee schedule,113.79,150,,,fee schedule,150% of cms physician fee schedule,75.86,150,
SUBSEQ HOSP CARE HIGH 50 MIN,32009061,CDM,987,RC,99233,HCPCS,outpatient,,,236.25,141.75,,,,,,other,not separately reimbusable,114.15,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,101.53,100,,,fee schedule,100% of cigna custom fee schedule,125.57,110,,,fee schedule,110% of cms physician fee schedule,115.29,101,,,fee schedule,101% of cms physician fee schedule ,115.29,116.15,,,fee schedule,116.51% of cms physician fee schedule,115.29,101,,,fee schedule,101% of cms physician fee schedule,216.89,110,,,fee schedule,110% of humana physician fee schedule,125.57,110,,,fee schedule,110% of humana physician fee schedule,171.23,150,,,fee schedule,100% of cms fee schedule,114.15,100,,,fee schedule,100% of cms physician fee schedule,171.23,150,,,fee schedule,150% of cms physician fee schedule,100,171.23,
Hsp Adm/dc Same Day Mod,43710019,CDM,987,RC,99235,HCPCS,outpatient,,,389.99,233.99,,,,,,other,not separately reimbusable,153.44,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,164.54,100,,,fee schedule,100% of cigna custom fee schedule,168.78,110,,,fee schedule,110% of cms physician fee schedule,154.97,101,,,fee schedule,101% of cms physician fee schedule ,154.97,116.15,,,fee schedule,116.51% of cms physician fee schedule,154.97,101,,,fee schedule,101% of cms physician fee schedule,291.54,110,,,fee schedule,110% of humana physician fee schedule,168.78,110,,,fee schedule,110% of humana physician fee schedule,230.16,150,,,fee schedule,100% of cms fee schedule,153.44,100,,,fee schedule,100% of cms physician fee schedule,230.16,150,,,fee schedule,150% of cms physician fee schedule,100,230.16,
HOSP DC SVC 30 OR LESS,43710012,CDM,987,RC,99238,HCPCS,outpatient,,,191.25,114.75,,,,,,other,not separately reimbusable,77.44,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,69.93,100,,,fee schedule,100% of cigna custom fee schedule,85.18,110,,,fee schedule,110% of cms physician fee schedule,78.21,101,,,fee schedule,101% of cms physician fee schedule ,78.21,116.15,,,fee schedule,116.51% of cms physician fee schedule,78.21,101,,,fee schedule,101% of cms physician fee schedule,147.14,110,,,fee schedule,110% of humana physician fee schedule,85.18,110,,,fee schedule,110% of humana physician fee schedule,116.16,150,,,fee schedule,100% of cms fee schedule,77.44,100,,,fee schedule,100% of cms physician fee schedule,116.16,150,,,fee schedule,150% of cms physician fee schedule,77.44,150,
HOSP D/C >30 MINS,43710013,CDM,987,RC,99239,HCPCS,outpatient,,,177.71,106.63,,,,,,other,not separately reimbusable,109.35,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,103.72,100,,,fee schedule,100% of cigna custom fee schedule,120.29,110,,,fee schedule,110% of cms physician fee schedule,110.44,101,,,fee schedule,101% of cms physician fee schedule ,110.44,116.15,,,fee schedule,116.51% of cms physician fee schedule,110.44,101,,,fee schedule,101% of cms physician fee schedule,207.77,110,,,fee schedule,110% of humana physician fee schedule,120.29,110,,,fee schedule,110% of humana physician fee schedule,164.03,150,,,fee schedule,100% of cms fee schedule,109.35,100,,,fee schedule,100% of cms physician fee schedule,164.03,150,,,fee schedule,150% of cms physician fee schedule,100,164.03,
HOSP ADM/DC SAME DAY LOW,43710018,CDM,762,RC,99234,HCPCS,outpatient,,,239.15,143.49,,143.49,60,,114.792,percent of total billed charges,60% of total billed charges,114.79,48,,91.832,percent of total billed charges,48% of total billed charges,119.58,50,,95.664,percent of total billed charges,50% of total billed charges,119.58,50,,95.664,percent of total billed charges,50% of total billed charges,119.58,50,,95.664,percent of total billed charges,50% of total billed charges,950,100,,,case rate,pays based on per visit rate,167.41,70,,133.928,percent of total billed charges,70% of total billed charges,115.94,48.48,,92.752,percent of total billed charges,48.48% of total billed charges,109.56,116.15,,,fee schedule,116.51% of cms physician fee schedule,115.94,48.48,,92.752,percent of total billed charges,48.48% of total billed charges,167.41,70,,133.928,percent of total billed charges,70% of total billed charges,167.41,70,,133.928,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,115.94,48.48,,92.752,percent of total billed charges,48.48% of total billed charges,215.24,90,,172.192,percent of total billed charges,90% of total billed charges,48.48,215.24,
INITIAL ADMIT 35 MIN,43710024,CDM,524,RC,99305,HCPCS,outpatient,,,210,126.00,,126,60,,100.8,percent of total billed charges,60% of total billed charges,100.8,48,,80.64,percent of total billed charges,48% of total billed charges,105,50,,84,percent of total billed charges,50% of total billed charges,105,50,,84,percent of total billed charges,50% of total billed charges,105,50,,84,percent of total billed charges,50% of total billed charges,,,,,other,not separately reimbusable,147,70,,117.6,percent of total billed charges,70% of total billed charges,101.81,48.48,,81.448,percent of total billed charges,48.48% of total billed charges,148.21,116.15,,,fee schedule,116.51% of cms physician fee schedule,101.81,48.48,,81.448,percent of total billed charges,48.48% of total billed charges,147,70,,117.6,percent of total billed charges,70% of total billed charges,147,70,,117.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,101.81,48.48,,81.448,percent of total billed charges,48.48% of total billed charges,189,90,,151.2,percent of total billed charges,90% of total billed charges,48.48,189,
SUBSEQ VISIT 10 MIN,43710026,CDM,524,RC,99307,HCPCS,outpatient,,,61.25,36.75,,36.75,60,,29.4,percent of total billed charges,60% of total billed charges,29.4,48,,23.52,percent of total billed charges,48% of total billed charges,30.63,50,,24.504,percent of total billed charges,50% of total billed charges,30.63,50,,24.504,percent of total billed charges,50% of total billed charges,30.63,50,,24.504,percent of total billed charges,50% of total billed charges,,,,,other,not separately reimbusable,42.88,70,,34.304,percent of total billed charges,70% of total billed charges,29.69,48.48,,23.752,percent of total billed charges,48.48% of total billed charges,44.51,116.15,,,fee schedule,116.51% of cms physician fee schedule,29.69,48.48,,23.752,percent of total billed charges,48.48% of total billed charges,42.88,70,,34.304,percent of total billed charges,70% of total billed charges,42.88,70,,34.304,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,29.69,48.48,,23.752,percent of total billed charges,48.48% of total billed charges,55.13,90,,44.104,percent of total billed charges,90% of total billed charges,29.69,90,
SUBSEQ VISIT 15 MIN,43710027,CDM,524,RC,99308,HCPCS,outpatient,,,134.75,80.85,,80.85,60,,64.68,percent of total billed charges,60% of total billed charges,64.68,48,,51.744,percent of total billed charges,48% of total billed charges,67.38,50,,53.904,percent of total billed charges,50% of total billed charges,67.38,50,,53.904,percent of total billed charges,50% of total billed charges,67.38,50,,53.904,percent of total billed charges,50% of total billed charges,,,,,other,not separately reimbusable,94.33,70,,75.464,percent of total billed charges,70% of total billed charges,65.33,48.48,,52.264,percent of total billed charges,48.48% of total billed charges,82.35,116.15,,,fee schedule,116.51% of cms physician fee schedule,65.33,48.48,,52.264,percent of total billed charges,48.48% of total billed charges,94.33,70,,75.464,percent of total billed charges,70% of total billed charges,94.33,70,,75.464,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,65.33,48.48,,52.264,percent of total billed charges,48.48% of total billed charges,121.28,90,,97.024,percent of total billed charges,90% of total billed charges,48.48,121.28,
SUBSEQ VISIT 25 MIN,43710028,CDM,524,RC,99309,HCPCS,outpatient,,,131.25,78.75,,78.75,60,,63,percent of total billed charges,60% of total billed charges,63,48,,50.4,percent of total billed charges,48% of total billed charges,65.63,50,,52.504,percent of total billed charges,50% of total billed charges,65.63,50,,52.504,percent of total billed charges,50% of total billed charges,65.63,50,,52.504,percent of total billed charges,50% of total billed charges,,,,,other,not separately reimbusable,91.88,70,,73.504,percent of total billed charges,70% of total billed charges,63.63,48.48,,50.904,percent of total billed charges,48.48% of total billed charges,119.26,116.15,,,fee schedule,116.51% of cms physician fee schedule,63.63,48.48,,50.904,percent of total billed charges,48.48% of total billed charges,91.88,70,,73.504,percent of total billed charges,70% of total billed charges,91.88,70,,73.504,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,63.63,48.48,,50.904,percent of total billed charges,48.48% of total billed charges,118.13,90,,94.504,percent of total billed charges,90% of total billed charges,48.48,118.13,
SWINGBED DC 30 OR LESS,43710030,CDM,524,RC,99315,HCPCS,outpatient,,,134.75,80.85,,80.85,60,,64.68,percent of total billed charges,60% of total billed charges,64.68,48,,51.744,percent of total billed charges,48% of total billed charges,67.38,50,,53.904,percent of total billed charges,50% of total billed charges,67.38,50,,53.904,percent of total billed charges,50% of total billed charges,67.38,50,,53.904,percent of total billed charges,50% of total billed charges,,,,,other,not separately reimbusable,94.33,70,,75.464,percent of total billed charges,70% of total billed charges,65.33,48.48,,52.264,percent of total billed charges,48.48% of total billed charges,90.53,116.15,,,fee schedule,116.51% of cms physician fee schedule,65.33,48.48,,52.264,percent of total billed charges,48.48% of total billed charges,94.33,70,,75.464,percent of total billed charges,70% of total billed charges,94.33,70,,75.464,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,65.33,48.48,,52.264,percent of total billed charges,48.48% of total billed charges,121.28,90,,97.024,percent of total billed charges,90% of total billed charges,48.48,121.28,
OBS DISCHARGE 30 MINS OR LESS,43710012,CDM,982,RC,99238,HCPCS,outpatient,,,173.75,104.25,,,,,,other,not separately reimbusable,77.44,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,69.93,100,,,fee schedule,100% of cigna custom fee schedule,85.18,110,,,fee schedule,110% of cms physician fee schedule,78.21,101,,,fee schedule,101% of cms physician fee schedule ,78.21,116.15,,,fee schedule,116.51% of cms physician fee schedule,78.21,101,,,fee schedule,101% of cms physician fee schedule,147.14,110,,,fee schedule,110% of humana physician fee schedule,85.18,110,,,fee schedule,110% of humana physician fee schedule,116.16,150,,,fee schedule,100% of cms fee schedule,77.44,100,,,fee schedule,100% of cms physician fee schedule,116.16,150,,,fee schedule,150% of cms physician fee schedule,77.44,150,
OBSERVATION SF/ LOW 40 MIN,43710006,CDM,982,RC,99221,HCPCS,outpatient,,,208.75,125.25,,,,,,other,not separately reimbusable,80.06,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,99.27,100,,,fee schedule,100% of cigna custom fee schedule,88.07,110,,,fee schedule,110% of cms physician fee schedule,80.86,101,,,fee schedule,101% of cms physician fee schedule ,80.86,116.15,,,fee schedule,116.51% of cms physician fee schedule,80.86,101,,,fee schedule,101% of cms physician fee schedule,152.11,110,,,fee schedule,110% of humana physician fee schedule,88.07,110,,,fee schedule,110% of humana physician fee schedule,120.09,150,,,fee schedule,100% of cms fee schedule,80.06,100,,,fee schedule,100% of cms physician fee schedule,120.09,150,,,fee schedule,150% of cms physician fee schedule,80.06,150,
OBSERVATION MODERATE 55 MIN,43710007,CDM,982,RC,99222,HCPCS,outpatient,,,295,177.00,,,,,,other,not separately reimbusable,125.92,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,133.43,100,,,fee schedule,100% of cigna custom fee schedule,138.51,110,,,fee schedule,110% of cms physician fee schedule,127.18,101,,,fee schedule,101% of cms physician fee schedule ,127.18,116.15,,,fee schedule,116.51% of cms physician fee schedule,127.18,101,,,fee schedule,101% of cms physician fee schedule,239.25,110,,,fee schedule,110% of humana physician fee schedule,138.51,110,,,fee schedule,110% of humana physician fee schedule,188.88,150,,,fee schedule,100% of cms fee schedule,125.92,100,,,fee schedule,100% of cms physician fee schedule,188.88,150,,,fee schedule,150% of cms physician fee schedule,100,188.88,
SUBSEQ OBS DAY MOD 35 MIN,32009060,CDM,982,RC,99232,HCPCS,outpatient,,,120,72.00,,,,,,other,not separately reimbusable,75.86,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,70.16,100,,,fee schedule,100% of cigna custom fee schedule,83.45,110,,,fee schedule,110% of cms physician fee schedule,76.62,101,,,fee schedule,101% of cms physician fee schedule ,76.62,116.15,,,fee schedule,116.51% of cms physician fee schedule,76.62,101,,,fee schedule,101% of cms physician fee schedule,144.13,110,,,fee schedule,110% of humana physician fee schedule,83.45,110,,,fee schedule,110% of humana physician fee schedule,113.79,150,,,fee schedule,100% of cms fee schedule,75.86,100,,,fee schedule,100% of cms physician fee schedule,113.79,150,,,fee schedule,150% of cms physician fee schedule,75.86,150,
OBSERVATION HIGH 75 MIN,43710008,CDM,982,RC,99223,HCPCS,outpatient,,,305,183.00,,,,,,other,not separately reimbusable,166.64,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,197.31,100,,,fee schedule,100% of cigna custom fee schedule,183.3,110,,,fee schedule,110% of cms physician fee schedule,168.31,101,,,fee schedule,101% of cms physician fee schedule ,168.31,116.15,,,fee schedule,116.51% of cms physician fee schedule,168.31,101,,,fee schedule,101% of cms physician fee schedule,316.62,110,,,fee schedule,110% of humana physician fee schedule,183.3,110,,,fee schedule,110% of humana physician fee schedule,249.96,150,,,fee schedule,100% of cms fee schedule,166.64,100,,,fee schedule,100% of cms physician fee schedule,249.96,150,,,fee schedule,150% of cms physician fee schedule,100,249.96,
BX/EXC LYMPH NODE; SUPERF,42001073,CDM,983,RC,38505,HCPCS,outpatient,,,1146.25,687.75,AQ,,,,,other,not separately reimbusable,81.76,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,129.31,100,,,fee schedule,100% of cigna custom fee schedule,89.94,110,,,fee schedule,110% of cms physician fee schedule,82.58,101,,,fee schedule,101% of cms physician fee schedule ,82.58,116.15,,,fee schedule,116.51% of cms physician fee schedule,82.58,101,,,fee schedule,101% of cms physician fee schedule,155.34,110,,,fee schedule,110% of humana physician fee schedule,89.94,110,,,fee schedule,110% of humana physician fee schedule,122.64,150,,,fee schedule,100% of cms fee schedule,81.76,100,,,fee schedule,100% of cms physician fee schedule,122.64,150,,,fee schedule,150% of cms physician fee schedule,81.76,150,
INSERTION TEMP INDWG CATH,36011020,CDM,982,RC,51702,HCPCS,outpatient,,,218.75,131.25,AQ,,,,,other,not separately reimbusable,24.46,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,39.39,100,,,fee schedule,100% of cigna custom fee schedule,26.91,110,,,fee schedule,110% of cms physician fee schedule,24.7,101,,,fee schedule,101% of cms physician fee schedule ,24.7,116.15,,,fee schedule,116.51% of cms physician fee schedule,24.7,101,,,fee schedule,101% of cms physician fee schedule,46.47,110,,,fee schedule,110% of humana physician fee schedule,26.91,110,,,fee schedule,110% of humana physician fee schedule,36.69,150,,,fee schedule,100% of cms fee schedule,24.46,100,,,fee schedule,100% of cms physician fee schedule,36.69,150,,,fee schedule,150% of cms physician fee schedule,24.46,150,
BX UTERUS LINING,43601167,CDM,981,RC,58100,HCPCS,outpatient,,,217.5,130.50,,,,,,other,not separately reimbusable,61.89,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,174.55,100,,,fee schedule,100% of cigna custom fee schedule,68.08,110,,,fee schedule,110% of cms physician fee schedule,62.51,101,,,fee schedule,101% of cms physician fee schedule ,62.51,116.15,,,fee schedule,116.51% of cms physician fee schedule,62.51,101,,,fee schedule,101% of cms physician fee schedule,117.59,110,,,fee schedule,110% of humana physician fee schedule,68.08,110,,,fee schedule,110% of humana physician fee schedule,92.84,150,,,fee schedule,100% of cms fee schedule,61.89,100,,,fee schedule,100% of cms physician fee schedule,92.84,150,,,fee schedule,150% of cms physician fee schedule,61.89,150,
CLOSED TX PATELLAR DISLOCATION,36010071,CDM,981,RC,27560,HCPCS,outpatient,,,396.25,237.75,,,,,,other,not separately reimbusable,334.04,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,607.35,100,,,fee schedule,100% of cigna custom fee schedule,367.44,110,,,fee schedule,110% of cms physician fee schedule,337.38,101,,,fee schedule,101% of cms physician fee schedule ,337.38,116.15,,,fee schedule,116.51% of cms physician fee schedule,337.38,101,,,fee schedule,101% of cms physician fee schedule,634.68,110,,,fee schedule,110% of humana physician fee schedule,367.44,110,,,fee schedule,110% of humana physician fee schedule,501.06,150,,,fee schedule,100% of cms fee schedule,334.04,100,,,fee schedule,100% of cms physician fee schedule,501.06,150,,,fee schedule,150% of cms physician fee schedule,100,501.06,
MIDLINE PLACEMENT,32001000,CDM,981,RC,36569,HCPCS,outpatient,,,275.94,165.56,,,,,,other,not separately reimbusable,91.78,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,169.32,100,,,fee schedule,100% of cigna custom fee schedule,100.96,110,,,fee schedule,110% of cms physician fee schedule,92.7,101,,,fee schedule,101% of cms physician fee schedule ,92.7,116.15,,,fee schedule,116.51% of cms physician fee schedule,92.7,101,,,fee schedule,101% of cms physician fee schedule,174.38,110,,,fee schedule,110% of humana physician fee schedule,100.96,110,,,fee schedule,110% of humana physician fee schedule,137.67,150,,,fee schedule,100% of cms fee schedule,91.78,100,,,fee schedule,100% of cms physician fee schedule,137.67,150,,,fee schedule,150% of cms physician fee schedule,91.78,150,
IRRIGATION OF CORPORA CAVERNOSA,,,981,RC,54220,HCPCS,outpatient,,,396.83,238.10,,,,,,other,not separately reimbusable,130.77,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,205.08,100,,,fee schedule,100% of cigna custom fee schedule,143.85,110,,,fee schedule,110% of cms physician fee schedule,132.08,101,,,fee schedule,101% of cms physician fee schedule ,132.08,116.15,,,fee schedule,116.51% of cms physician fee schedule,132.08,101,,,fee schedule,101% of cms physician fee schedule,248.46,110,,,fee schedule,110% of humana physician fee schedule,143.85,110,,,fee schedule,110% of humana physician fee schedule,196.16,150,,,fee schedule,100% of cms fee schedule,130.77,100,,,fee schedule,100% of cms physician fee schedule,196.16,150,,,fee schedule,150% of cms physician fee schedule,100,196.16,
PF TREAT LOWER LEG FRACTURE,,,981,RC,27825,HCPCS,outpatient,,,593,355.80,,,,,,other,not separately reimbusable,480.57,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,917.87,100,,,fee schedule,100% of cigna custom fee schedule,528.63,110,,,fee schedule,110% of cms physician fee schedule,485.38,101,,,fee schedule,101% of cms physician fee schedule ,485.38,116.15,,,fee schedule,116.51% of cms physician fee schedule,485.38,101,,,fee schedule,101% of cms physician fee schedule,913.08,110,,,fee schedule,110% of humana physician fee schedule,528.63,110,,,fee schedule,110% of humana physician fee schedule,720.86,150,,,fee schedule,100% of cms fee schedule,480.57,100,,,fee schedule,100% of cms physician fee schedule,720.86,150,,,fee schedule,150% of cms physician fee schedule,100,720.86,
PF TREAT RADIUS/ULNA FRACTURE,36010048,CDM,981,RC,25605,HCPCS,outpatient,,,545.85,327.51,,,,,,other,not separately reimbusable,498.52,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,939,100,,,fee schedule,100% of cigna custom fee schedule,548.37,110,,,fee schedule,110% of cms physician fee schedule,503.51,101,,,fee schedule,101% of cms physician fee schedule ,503.51,116.15,,,fee schedule,116.51% of cms physician fee schedule,503.51,101,,,fee schedule,101% of cms physician fee schedule,947.19,110,,,fee schedule,110% of humana physician fee schedule,548.37,110,,,fee schedule,110% of humana physician fee schedule,747.78,150,,,fee schedule,100% of cms fee schedule,498.52,100,,,fee schedule,100% of cms physician fee schedule,747.78,150,,,fee schedule,150% of cms physician fee schedule,100,747.78,
PF SHAVE SKN LES <.5,43601387,CDM,982,RC,11300,HCPCS,outpatient,,,212.75,127.65,,,,,,other,not separately reimbusable,32.55,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,41.89,100,,,fee schedule,100% of cigna custom fee schedule,35.81,110,,,fee schedule,110% of cms physician fee schedule,32.88,101,,,fee schedule,101% of cms physician fee schedule ,32.88,116.15,,,fee schedule,116.51% of cms physician fee schedule,32.88,101,,,fee schedule,101% of cms physician fee schedule,61.85,110,,,fee schedule,110% of humana physician fee schedule,35.81,110,,,fee schedule,110% of humana physician fee schedule,48.83,150,,,fee schedule,100% of cms fee schedule,32.55,100,,,fee schedule,100% of cms physician fee schedule,48.83,150,,,fee schedule,150% of cms physician fee schedule,32.55,150,
CMPLX RPR S/A/L ADDL 5 CM/>,36010215,CDM,981,RC,13122,HCPCS,outpatient,,,353.64,212.18,22,,,,,other,not separately reimbusable,79.34,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,158.37,100,,,fee schedule,100% of cigna custom fee schedule,87.27,110,,,fee schedule,110% of cms physician fee schedule,80.13,101,,,fee schedule,101% of cms physician fee schedule ,80.13,116.15,,,fee schedule,116.51% of cms physician fee schedule,80.13,101,,,fee schedule,101% of cms physician fee schedule,150.75,110,,,fee schedule,110% of humana physician fee schedule,87.27,110,,,fee schedule,110% of humana physician fee schedule,119.01,150,,,fee schedule,100% of cms fee schedule,79.34,100,,,fee schedule,100% of cms physician fee schedule,119.01,150,,,fee schedule,150% of cms physician fee schedule,79.34,150,
PHY SHAVE BX SINGLE LESION,43601381,CDM,981,RC,11102,HCPCS,outpatient,,,122.36,73.42,,,,,,other,not separately reimbusable,36,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,46.78,100,,,fee schedule,100% of cigna custom fee schedule,39.6,110,,,fee schedule,110% of cms physician fee schedule,36.36,101,,,fee schedule,101% of cms physician fee schedule ,36.36,116.15,,,fee schedule,116.51% of cms physician fee schedule,36.36,101,,,fee schedule,101% of cms physician fee schedule,68.4,110,,,fee schedule,110% of humana physician fee schedule,39.6,110,,,fee schedule,110% of humana physician fee schedule,54,150,,,fee schedule,100% of cms fee schedule,36,100,,,fee schedule,100% of cms physician fee schedule,54,150,,,fee schedule,150% of cms physician fee schedule,36,150,
PHY FEE TREATMENT FINGER FX,36010059,CDM,981,RC,26725,HCPCS,outpatient,,,362.5,217.50,,,,,,other,not separately reimbusable,298.41,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,552.8,100,,,fee schedule,100% of cigna custom fee schedule,328.25,110,,,fee schedule,110% of cms physician fee schedule,301.39,101,,,fee schedule,101% of cms physician fee schedule ,301.39,116.15,,,fee schedule,116.51% of cms physician fee schedule,301.39,101,,,fee schedule,101% of cms physician fee schedule,566.98,110,,,fee schedule,110% of humana physician fee schedule,328.25,110,,,fee schedule,110% of humana physician fee schedule,447.62,150,,,fee schedule,100% of cms fee schedule,298.41,100,,,fee schedule,100% of cms physician fee schedule,447.62,150,,,fee schedule,150% of cms physician fee schedule,100,447.62,
RESET DISLOCATED JAW,36010211,CDM,981,RC,21480,HCPCS,outpatient,,,152.5,91.50,,,,,,other,not separately reimbusable,30.7,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,61.29,100,,,fee schedule,100% of cigna custom fee schedule,33.77,110,,,fee schedule,110% of cms physician fee schedule,31.01,101,,,fee schedule,101% of cms physician fee schedule ,31.01,116.15,,,fee schedule,116.51% of cms physician fee schedule,31.01,101,,,fee schedule,101% of cms physician fee schedule,58.33,110,,,fee schedule,110% of humana physician fee schedule,33.77,110,,,fee schedule,110% of humana physician fee schedule,46.05,150,,,fee schedule,100% of cms fee schedule,30.7,100,,,fee schedule,100% of cms physician fee schedule,46.05,150,,,fee schedule,150% of cms physician fee schedule,30.7,150,
PLACEMENT NEEDLE INTRAOSSEOUS INFUSE,36011054,CDM,981,RC,36680,HCPCS,outpatient,,,157.64,94.58,,,,,,other,not separately reimbusable,58.52,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,109.87,100,,,fee schedule,100% of cigna custom fee schedule,64.37,110,,,fee schedule,110% of cms physician fee schedule,59.11,101,,,fee schedule,101% of cms physician fee schedule ,59.11,116.15,,,fee schedule,116.51% of cms physician fee schedule,59.11,101,,,fee schedule,101% of cms physician fee schedule,111.19,110,,,fee schedule,110% of humana physician fee schedule,64.37,110,,,fee schedule,110% of humana physician fee schedule,87.78,150,,,fee schedule,100% of cms fee schedule,58.52,100,,,fee schedule,100% of cms physician fee schedule,87.78,150,,,fee schedule,150% of cms physician fee schedule,58.52,150,
PHY CHRG/CLTX RDL HEAD SUBLXTJ CHILD ELB,36010041,CDM,981,RC,24640,HCPCS,outpatient,,,186.76,112.06,,,,,,other,not separately reimbusable,76.52,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,158.71,100,,,fee schedule,100% of cigna custom fee schedule,84.17,110,,,fee schedule,110% of cms physician fee schedule,77.29,101,,,fee schedule,101% of cms physician fee schedule ,77.29,116.15,,,fee schedule,116.51% of cms physician fee schedule,77.29,101,,,fee schedule,101% of cms physician fee schedule,145.39,110,,,fee schedule,110% of humana physician fee schedule,84.17,110,,,fee schedule,110% of humana physician fee schedule,114.78,150,,,fee schedule,100% of cms fee schedule,76.52,100,,,fee schedule,100% of cms physician fee schedule,114.78,150,,,fee schedule,150% of cms physician fee schedule,76.52,150,
EXC MAL LESION S/N/H/F/G 2.1-3.0 CM,,,982,RC,11623,HCPCS,outpatient,,,510.96,306.58,,,,,,other,not separately reimbusable,198.65,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,249.18,100,,,fee schedule,100% of cigna custom fee schedule,218.52,110,,,fee schedule,110% of cms physician fee schedule,200.64,101,,,fee schedule,101% of cms physician fee schedule ,200.64,116.15,,,fee schedule,116.51% of cms physician fee schedule,200.64,101,,,fee schedule,101% of cms physician fee schedule,377.44,110,,,fee schedule,110% of humana physician fee schedule,218.52,110,,,fee schedule,110% of humana physician fee schedule,297.98,150,,,fee schedule,100% of cms fee schedule,198.65,100,,,fee schedule,100% of cms physician fee schedule,297.98,150,,,fee schedule,150% of cms physician fee schedule,100,297.98,
REPAIR BLOOD VESSEL LOWER EXTREMITY ED,36011034,CDM,450,RC,35226,HCPCS,outpatient,,,4405.17,2643.10,,756,100,,,fee schedule,100% of asc tier groupings rate,2114.48,48,,1691.584,percent of total billed charges,48% of total billed charges,3791.07,100,,,fee schedule,100% of bcbs custom fee schedule,3791.07,100,,,fee schedule,100% of bcbs custom fee schedule,4208.09,111,,,fee schedule,111% of bcbs custom fee schedule,2202.59,50,,1762.072,percent of total billed charges,50% of total billed charges,3083.62,70,,2466.896,percent of total billed charges,70% of total billed charges,2135.63,48.48,,1708.504,percent of total billed charges,48.48% of total billed charges,936.61,116.15,,,fee schedule,116.51% of cms physician fee schedule,2135.63,48.48,,1708.504,percent of total billed charges,48.48% of total billed charges,3083.62,70,,2466.896,percent of total billed charges,70% of total billed charges,3083.62,70,,2466.896,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,2135.63,48.48,,1708.504,percent of total billed charges,48.48% of total billed charges,3964.65,90,,3171.72,percent of total billed charges,90% of total billed charges,48.48,3964.65,
REPAIR BLOOD VESSEL LOVER EXTREMITY PHY,36011034,CDM,981,RC,35226,HCPCS,outpatient,,,2583.39,1550.03,,,,,,other,not separately reimbusable,806.38,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,1519.35,100,,,fee schedule,100% of cigna custom fee schedule,887.02,110,,,fee schedule,110% of cms physician fee schedule,814.44,101,,,fee schedule,101% of cms physician fee schedule ,814.44,116.15,,,fee schedule,116.51% of cms physician fee schedule,814.44,101,,,fee schedule,101% of cms physician fee schedule,1532.12,110,,,fee schedule,110% of humana physician fee schedule,887.02,110,,,fee schedule,110% of humana physician fee schedule,1209.57,150,,,fee schedule,100% of cms fee schedule,806.38,100,,,fee schedule,100% of cms physician fee schedule,1209.57,150,,,fee schedule,150% of cms physician fee schedule,100,1209.57,
ENEMA-FLEETS AND ADMIN,,,230,RC,,,outpatient,,,70.31,42.19,,42.19,60,,33.752,percent of total billed charges,60% of total billed charges,33.75,48,,27,percent of total billed charges,48% of total billed charges,35.16,50,,28.128,percent of total billed charges,50% of total billed charges,35.16,50,,28.128,percent of total billed charges,50% of total billed charges,35.16,50,,28.128,percent of total billed charges,50% of total billed charges,35.16,50,,28.128,percent of total billed charges,50% of total billed charges,49.22,70,,39.376,percent of total billed charges,70% of total billed charges,34.09,48.48,,27.272,percent of total billed charges,48.48% of total billed charges,34.09,48.48,,27.272,percent of total billed charges,48.48% of total billed charges,34.09,48.48,,27.272,percent of total billed charges,48.48% of total billed charges,49.22,70,,39.376,percent of total billed charges,70% of total billed charges,49.22,70,,39.376,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,34.09,48.48,,27.272,percent of total billed charges,48.48% of total billed charges,63.28,90,,50.624,percent of total billed charges,90% of total billed charges,34.09,90,
ENEMA REGULAR AND ADMIN,,,270,RC,,,outpatient,,,70.31,42.19,,42.19,60,,33.752,percent of total billed charges,60% of total billed charges,33.75,48,,27,percent of total billed charges,48% of total billed charges,35.16,50,,28.128,percent of total billed charges,50% of total billed charges,35.16,50,,28.128,percent of total billed charges,50% of total billed charges,35.16,50,,28.128,percent of total billed charges,50% of total billed charges,35.16,50,,28.128,percent of total billed charges,50% of total billed charges,49.22,70,,39.376,percent of total billed charges,70% of total billed charges,34.09,48.48,,27.272,percent of total billed charges,48.48% of total billed charges,34.09,48.48,,27.272,percent of total billed charges,48.48% of total billed charges,34.09,48.48,,27.272,percent of total billed charges,48.48% of total billed charges,49.22,70,,39.376,percent of total billed charges,70% of total billed charges,49.22,70,,39.376,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,34.09,48.48,,27.272,percent of total billed charges,48.48% of total billed charges,63.28,90,,50.624,percent of total billed charges,90% of total billed charges,34.09,90,
Tracheostomy Oxygen Mask,,,270,RC,A7525,HCPCS,outpatient,,,16.83,10.10,,10.1,60,,8.08,percent of total billed charges,60% of total billed charges,8.08,48,,6.464,percent of total billed charges,48% of total billed charges,8.42,50,,6.736,percent of total billed charges,50% of total billed charges,8.42,50,,6.736,percent of total billed charges,50% of total billed charges,8.42,50,,6.736,percent of total billed charges,50% of total billed charges,8.42,50,,6.736,percent of total billed charges,50% of total billed charges,11.78,70,,9.424,percent of total billed charges,70% of total billed charges,8.16,48.48,,6.528,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,8.16,48.48,,6.528,percent of total billed charges,48.48% of total billed charges,11.78,70,,9.424,percent of total billed charges,70% of total billed charges,11.78,70,,9.424,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,8.16,48.48,,6.528,percent of total billed charges,48.48% of total billed charges,15.15,90,,12.12,percent of total billed charges,90% of total billed charges,8.16,90,
ENEMA FOR IMPACTION,,,270,RC,,,outpatient,,,110.94,66.56,,66.56,60,,53.248,percent of total billed charges,60% of total billed charges,53.25,48,,42.6,percent of total billed charges,48% of total billed charges,55.47,50,,44.376,percent of total billed charges,50% of total billed charges,55.47,50,,44.376,percent of total billed charges,50% of total billed charges,55.47,50,,44.376,percent of total billed charges,50% of total billed charges,55.47,50,,44.376,percent of total billed charges,50% of total billed charges,77.66,70,,62.128,percent of total billed charges,70% of total billed charges,53.78,48.48,,43.024,percent of total billed charges,48.48% of total billed charges,53.78,48.48,,43.024,percent of total billed charges,48.48% of total billed charges,53.78,48.48,,43.024,percent of total billed charges,48.48% of total billed charges,77.66,70,,62.128,percent of total billed charges,70% of total billed charges,77.66,70,,62.128,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,53.78,48.48,,43.024,percent of total billed charges,48.48% of total billed charges,99.85,90,,79.88,percent of total billed charges,90% of total billed charges,48.48,99.85,
ISOLATION CHG TOTAL/DAY,,,270,RC,,,outpatient,,,235.94,141.56,,141.56,60,,113.248,percent of total billed charges,60% of total billed charges,113.25,48,,90.6,percent of total billed charges,48% of total billed charges,117.97,50,,94.376,percent of total billed charges,50% of total billed charges,117.97,50,,94.376,percent of total billed charges,50% of total billed charges,117.97,50,,94.376,percent of total billed charges,50% of total billed charges,117.97,50,,94.376,percent of total billed charges,50% of total billed charges,165.16,70,,132.128,percent of total billed charges,70% of total billed charges,114.38,48.48,,91.504,percent of total billed charges,48.48% of total billed charges,114.38,48.48,,91.504,percent of total billed charges,48.48% of total billed charges,114.38,48.48,,91.504,percent of total billed charges,48.48% of total billed charges,165.16,70,,132.128,percent of total billed charges,70% of total billed charges,165.16,70,,132.128,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,114.38,48.48,,91.504,percent of total billed charges,48.48% of total billed charges,212.35,90,,169.88,percent of total billed charges,90% of total billed charges,48.48,212.35,
CODE BLUE SUPPLIES,,,270,RC,,,outpatient,,,625,375.00,,375,60,,300,percent of total billed charges,60% of total billed charges,300,48,,240,percent of total billed charges,48% of total billed charges,312.5,50,,250,percent of total billed charges,50% of total billed charges,312.5,50,,250,percent of total billed charges,50% of total billed charges,312.5,50,,250,percent of total billed charges,50% of total billed charges,312.5,50,,250,percent of total billed charges,50% of total billed charges,437.5,70,,350,percent of total billed charges,70% of total billed charges,303,48.48,,242.4,percent of total billed charges,48.48% of total billed charges,303,48.48,,242.4,percent of total billed charges,48.48% of total billed charges,303,48.48,,242.4,percent of total billed charges,48.48% of total billed charges,437.5,70,,350,percent of total billed charges,70% of total billed charges,437.5,70,,350,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,303,48.48,,242.4,percent of total billed charges,48.48% of total billed charges,562.5,90,,450,percent of total billed charges,90% of total billed charges,48.48,562.5,
EAR IRRIGATION,,,450,RC,,,outpatient,,,78.13,46.88,,46.88,60,,37.504,percent of total billed charges,60% of total billed charges,37.5,48,,30,percent of total billed charges,48% of total billed charges,39.07,50,,31.256,percent of total billed charges,50% of total billed charges,39.07,50,,31.256,percent of total billed charges,50% of total billed charges,39.07,50,,31.256,percent of total billed charges,50% of total billed charges,39.07,50,,31.256,percent of total billed charges,50% of total billed charges,54.69,70,,43.752,percent of total billed charges,70% of total billed charges,37.88,48.48,,30.304,percent of total billed charges,48.48% of total billed charges,37.88,48.48,,30.304,percent of total billed charges,48.48% of total billed charges,37.88,48.48,,30.304,percent of total billed charges,48.48% of total billed charges,54.69,70,,43.752,percent of total billed charges,70% of total billed charges,54.69,70,,43.752,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,37.88,48.48,,30.304,percent of total billed charges,48.48% of total billed charges,70.32,90,,56.256,percent of total billed charges,90% of total billed charges,37.88,90,
EYE IRRIGATION-MINOR,,,270,RC,,,outpatient,,,78.13,46.88,,46.88,60,,37.504,percent of total billed charges,60% of total billed charges,37.5,48,,30,percent of total billed charges,48% of total billed charges,39.07,50,,31.256,percent of total billed charges,50% of total billed charges,39.07,50,,31.256,percent of total billed charges,50% of total billed charges,39.07,50,,31.256,percent of total billed charges,50% of total billed charges,39.07,50,,31.256,percent of total billed charges,50% of total billed charges,54.69,70,,43.752,percent of total billed charges,70% of total billed charges,37.88,48.48,,30.304,percent of total billed charges,48.48% of total billed charges,37.88,48.48,,30.304,percent of total billed charges,48.48% of total billed charges,37.88,48.48,,30.304,percent of total billed charges,48.48% of total billed charges,54.69,70,,43.752,percent of total billed charges,70% of total billed charges,54.69,70,,43.752,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,37.88,48.48,,30.304,percent of total billed charges,48.48% of total billed charges,70.32,90,,56.256,percent of total billed charges,90% of total billed charges,37.88,90,
BLOOD ADMIN KIT,,,270,RC,,,outpatient,,,117.19,70.31,,70.31,60,,56.248,percent of total billed charges,60% of total billed charges,56.25,48,,45,percent of total billed charges,48% of total billed charges,58.6,50,,46.88,percent of total billed charges,50% of total billed charges,58.6,50,,46.88,percent of total billed charges,50% of total billed charges,58.6,50,,46.88,percent of total billed charges,50% of total billed charges,58.6,50,,46.88,percent of total billed charges,50% of total billed charges,82.03,70,,65.624,percent of total billed charges,70% of total billed charges,56.81,48.48,,45.448,percent of total billed charges,48.48% of total billed charges,56.81,48.48,,45.448,percent of total billed charges,48.48% of total billed charges,56.81,48.48,,45.448,percent of total billed charges,48.48% of total billed charges,82.03,70,,65.624,percent of total billed charges,70% of total billed charges,82.03,70,,65.624,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,56.81,48.48,,45.448,percent of total billed charges,48.48% of total billed charges,105.47,90,,84.376,percent of total billed charges,90% of total billed charges,48.48,105.47,
VAGINAL EXAM TRAY,,,270,RC,,,outpatient,,,78.13,46.88,,46.88,60,,37.504,percent of total billed charges,60% of total billed charges,37.5,48,,30,percent of total billed charges,48% of total billed charges,39.07,50,,31.256,percent of total billed charges,50% of total billed charges,39.07,50,,31.256,percent of total billed charges,50% of total billed charges,39.07,50,,31.256,percent of total billed charges,50% of total billed charges,39.07,50,,31.256,percent of total billed charges,50% of total billed charges,54.69,70,,43.752,percent of total billed charges,70% of total billed charges,37.88,48.48,,30.304,percent of total billed charges,48.48% of total billed charges,37.88,48.48,,30.304,percent of total billed charges,48.48% of total billed charges,37.88,48.48,,30.304,percent of total billed charges,48.48% of total billed charges,54.69,70,,43.752,percent of total billed charges,70% of total billed charges,54.69,70,,43.752,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,37.88,48.48,,30.304,percent of total billed charges,48.48% of total billed charges,70.32,90,,56.256,percent of total billed charges,90% of total billed charges,37.88,90,
ENEMA ADMINISTRATION,,,230,RC,,,outpatient,,,32.81,19.69,,19.69,60,,15.752,percent of total billed charges,60% of total billed charges,15.75,48,,12.6,percent of total billed charges,48% of total billed charges,16.41,50,,13.128,percent of total billed charges,50% of total billed charges,16.41,50,,13.128,percent of total billed charges,50% of total billed charges,16.41,50,,13.128,percent of total billed charges,50% of total billed charges,16.41,50,,13.128,percent of total billed charges,50% of total billed charges,22.97,70,,18.376,percent of total billed charges,70% of total billed charges,15.91,48.48,,12.728,percent of total billed charges,48.48% of total billed charges,15.91,48.48,,12.728,percent of total billed charges,48.48% of total billed charges,15.91,48.48,,12.728,percent of total billed charges,48.48% of total billed charges,22.97,70,,18.376,percent of total billed charges,70% of total billed charges,22.97,70,,18.376,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,15.91,48.48,,12.728,percent of total billed charges,48.48% of total billed charges,29.53,90,,23.624,percent of total billed charges,90% of total billed charges,15.91,90,
I & D OF ABS/SIMPLE,36010135,CDM,761,RC,10060,HCPCS,outpatient,,,353.49,212.09,,399,100,,,fee schedule,100% of asc tier groupings rate,169.68,48,,135.744,percent of total billed charges,48% of total billed charges,322.02,100,,,fee schedule,100% of bcbs custom fee schedule,322.02,100,,,fee schedule,100% of bcbs custom fee schedule,357.44,111,,,fee schedule,111% of bcbs custom fee schedule,176.75,50,,141.4,percent of total billed charges,50% of total billed charges,247.44,70,,197.952,percent of total billed charges,70% of total billed charges,171.37,48.48,,137.096,percent of total billed charges,48.48% of total billed charges,116.25,116.15,,,fee schedule,116.51% of cms physician fee schedule,171.37,48.48,,137.096,percent of total billed charges,48.48% of total billed charges,247.44,70,,197.952,percent of total billed charges,70% of total billed charges,247.44,70,,197.952,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,171.37,48.48,,137.096,percent of total billed charges,48.48% of total billed charges,318.14,90,,254.512,percent of total billed charges,90% of total billed charges,48.48,318.14,
DRAINAGE OF FINGER ABSCES,36011037,CDM,761,RC,26010,HCPCS,outpatient,,,275,165.00,,165,60,,132,percent of total billed charges,60% of total billed charges,132,48,,105.6,percent of total billed charges,48% of total billed charges,245.57,100,,,fee schedule,100% of bcbs custom fee schedule,245.57,100,,,fee schedule,100% of bcbs custom fee schedule,272.58,111,,,fee schedule,111% of bcbs custom fee schedule,137.5,50,,110,percent of total billed charges,50% of total billed charges,192.5,70,,154,percent of total billed charges,70% of total billed charges,133.32,48.48,,106.656,percent of total billed charges,48.48% of total billed charges,156.05,116.15,,,fee schedule,116.51% of cms physician fee schedule,133.32,48.48,,106.656,percent of total billed charges,48.48% of total billed charges,192.5,70,,154,percent of total billed charges,70% of total billed charges,192.5,70,,154,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,133.32,48.48,,106.656,percent of total billed charges,48.48% of total billed charges,247.5,90,,198,percent of total billed charges,90% of total billed charges,48.48,247.5,
I & D CYST COPM/MULTIPLE,36010001,CDM,761,RC,10061,HCPCS,outpatient,,,554.76,332.86,,399,100,,,fee schedule,100% of asc tier groupings rate,266.28,48,,213.024,percent of total billed charges,48% of total billed charges,623.84,100,,,fee schedule,100% of bcbs custom fee schedule,623.84,100,,,fee schedule,100% of bcbs custom fee schedule,692.46,111,,,fee schedule,111% of bcbs custom fee schedule,277.38,50,,221.904,percent of total billed charges,50% of total billed charges,388.33,70,,310.664,percent of total billed charges,70% of total billed charges,268.95,48.48,,215.16,percent of total billed charges,48.48% of total billed charges,203.37,116.15,,,fee schedule,116.51% of cms physician fee schedule,268.95,48.48,,215.16,percent of total billed charges,48.48% of total billed charges,388.33,70,,310.664,percent of total billed charges,70% of total billed charges,388.33,70,,310.664,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,268.95,48.48,,215.16,percent of total billed charges,48.48% of total billed charges,499.28,90,,399.424,percent of total billed charges,90% of total billed charges,48.48,499.28,
I&D PILONIDAL CYST;SMPLE,36010189,CDM,761,RC,10080,HCPCS,outpatient,,,275,165.00,,399,100,,,fee schedule,100% of asc tier groupings rate,132,48,,105.6,percent of total billed charges,48% of total billed charges,1583.26,100,,,fee schedule,100% of bcbs custom fee schedule,1583.26,100,,,fee schedule,100% of bcbs custom fee schedule,1757.42,111,,,fee schedule,111% of bcbs custom fee schedule,137.5,50,,110,percent of total billed charges,50% of total billed charges,192.5,70,,154,percent of total billed charges,70% of total billed charges,133.32,48.48,,106.656,percent of total billed charges,48.48% of total billed charges,115.62,116.15,,,fee schedule,116.51% of cms physician fee schedule,133.32,48.48,,106.656,percent of total billed charges,48.48% of total billed charges,192.5,70,,154,percent of total billed charges,70% of total billed charges,192.5,70,,154,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,133.32,48.48,,106.656,percent of total billed charges,48.48% of total billed charges,247.5,90,,198,percent of total billed charges,90% of total billed charges,48.48,247.5,
INC & REM FB SQ TISS;SMPL,36010005,CDM,761,RC,10120,HCPCS,outpatient,,,459.38,275.63,AQ,399,100,,,fee schedule,100% of asc tier groupings rate,220.5,48,,176.4,percent of total billed charges,48% of total billed charges,616.4,100,,,fee schedule,100% of bcbs custom fee schedule,616.4,100,,,fee schedule,100% of bcbs custom fee schedule,684.2,111,,,fee schedule,111% of bcbs custom fee schedule,229.69,50,,183.752,percent of total billed charges,50% of total billed charges,321.57,70,,257.256,percent of total billed charges,70% of total billed charges,222.71,48.48,,178.168,percent of total billed charges,48.48% of total billed charges,115.44,116.15,,,fee schedule,116.51% of cms physician fee schedule,222.71,48.48,,178.168,percent of total billed charges,48.48% of total billed charges,321.57,70,,257.256,percent of total billed charges,70% of total billed charges,321.57,70,,257.256,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,222.71,48.48,,178.168,percent of total billed charges,48.48% of total billed charges,413.44,90,,330.752,percent of total billed charges,90% of total billed charges,48.48,413.44,
I & D/HEMATOMA,36010194,CDM,761,RC,10140,HCPCS,outpatient,,,294.65,176.79,,399,100,,,fee schedule,100% of asc tier groupings rate,141.43,48,,113.144,percent of total billed charges,48% of total billed charges,2574.32,100,,,fee schedule,100% of bcbs custom fee schedule,2574.32,100,,,fee schedule,100% of bcbs custom fee schedule,2857.5,111,,,fee schedule,111% of bcbs custom fee schedule,147.33,50,,117.864,percent of total billed charges,50% of total billed charges,206.26,70,,165.008,percent of total billed charges,70% of total billed charges,142.85,48.48,,114.28,percent of total billed charges,48.48% of total billed charges,130.66,116.15,,,fee schedule,116.51% of cms physician fee schedule,142.85,48.48,,114.28,percent of total billed charges,48.48% of total billed charges,206.26,70,,165.008,percent of total billed charges,70% of total billed charges,206.26,70,,165.008,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,142.85,48.48,,114.28,percent of total billed charges,48.48% of total billed charges,265.19,90,,212.152,percent of total billed charges,90% of total billed charges,48.48,265.19,
Wrist Splint - Colles',36039193,CDM,273,RC,L3908,HCPCS,outpatient,,,34.35,20.61,,20.61,60,,16.488,percent of total billed charges,60% of total billed charges,16.49,48,,13.192,percent of total billed charges,48% of total billed charges,17.18,50,,13.744,percent of total billed charges,50% of total billed charges,17.18,50,,13.744,percent of total billed charges,50% of total billed charges,17.18,50,,13.744,percent of total billed charges,50% of total billed charges,17.18,50,,13.744,percent of total billed charges,50% of total billed charges,24.05,70,,19.24,percent of total billed charges,70% of total billed charges,16.65,48.48,,13.32,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,16.65,48.48,,13.32,percent of total billed charges,48.48% of total billed charges,24.05,70,,19.24,percent of total billed charges,70% of total billed charges,24.05,70,,19.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,16.65,48.48,,13.32,percent of total billed charges,48.48% of total billed charges,30.92,90,,24.736,percent of total billed charges,90% of total billed charges,16.65,90,
DEBR EXZ/INF SKIN; 10% BS,36010006,CDM,761,RC,11000,HCPCS,outpatient,,,1416.32,849.79,,399,100,,,fee schedule,100% of asc tier groupings rate,679.83,48,,543.864,percent of total billed charges,48% of total billed charges,1171.5,100,,,fee schedule,100% of bcbs custom fee schedule,1171.5,100,,,fee schedule,100% of bcbs custom fee schedule,1300.37,111,,,fee schedule,111% of bcbs custom fee schedule,708.16,50,,566.528,percent of total billed charges,50% of total billed charges,991.42,70,,793.136,percent of total billed charges,70% of total billed charges,686.63,48.48,,549.304,percent of total billed charges,48.48% of total billed charges,31.16,116.15,,,fee schedule,116.51% of cms physician fee schedule,686.63,48.48,,549.304,percent of total billed charges,48.48% of total billed charges,991.42,70,,793.136,percent of total billed charges,70% of total billed charges,991.42,70,,793.136,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,686.63,48.48,,549.304,percent of total billed charges,48.48% of total billed charges,1274.69,90,,1019.752,percent of total billed charges,90% of total billed charges,48.48,1274.69,
Ankle Stirrup Brace,,,273,RC,L1904,HCPCS,outpatient,,,60.81,36.49,,36.49,60,,29.192,percent of total billed charges,60% of total billed charges,29.19,48,,23.352,percent of total billed charges,48% of total billed charges,30.41,50,,24.328,percent of total billed charges,50% of total billed charges,30.41,50,,24.328,percent of total billed charges,50% of total billed charges,30.41,50,,24.328,percent of total billed charges,50% of total billed charges,30.41,50,,24.328,percent of total billed charges,50% of total billed charges,42.57,70,,34.056,percent of total billed charges,70% of total billed charges,29.48,48.48,,23.584,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,29.48,48.48,,23.584,percent of total billed charges,48.48% of total billed charges,42.57,70,,34.056,percent of total billed charges,70% of total billed charges,42.57,70,,34.056,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,29.48,48.48,,23.584,percent of total billed charges,48.48% of total billed charges,54.73,90,,43.784,percent of total billed charges,90% of total billed charges,29.48,90,
Cervical Collar with Trach Opening,,,273,RC,L0174,HCPCS,outpatient,,,58.88,35.33,,35.33,60,,28.264,percent of total billed charges,60% of total billed charges,28.26,48,,22.608,percent of total billed charges,48% of total billed charges,29.44,50,,23.552,percent of total billed charges,50% of total billed charges,29.44,50,,23.552,percent of total billed charges,50% of total billed charges,29.44,50,,23.552,percent of total billed charges,50% of total billed charges,29.44,50,,23.552,percent of total billed charges,50% of total billed charges,41.22,70,,32.976,percent of total billed charges,70% of total billed charges,28.55,48.48,,22.84,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,28.55,48.48,,22.84,percent of total billed charges,48.48% of total billed charges,41.22,70,,32.976,percent of total billed charges,70% of total billed charges,41.22,70,,32.976,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,28.55,48.48,,22.84,percent of total billed charges,48.48% of total billed charges,52.99,90,,42.392,percent of total billed charges,90% of total billed charges,28.55,90,
Knee Immobilizer,36039196,CDM,273,RC,L1830,HCPCS,outpatient,,,67.38,40.43,,40.43,60,,32.344,percent of total billed charges,60% of total billed charges,32.34,48,,25.872,percent of total billed charges,48% of total billed charges,33.69,50,,26.952,percent of total billed charges,50% of total billed charges,33.69,50,,26.952,percent of total billed charges,50% of total billed charges,33.69,50,,26.952,percent of total billed charges,50% of total billed charges,33.69,50,,26.952,percent of total billed charges,50% of total billed charges,47.17,70,,37.736,percent of total billed charges,70% of total billed charges,32.67,48.48,,26.136,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,32.67,48.48,,26.136,percent of total billed charges,48.48% of total billed charges,47.17,70,,37.736,percent of total billed charges,70% of total billed charges,47.17,70,,37.736,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,32.67,48.48,,26.136,percent of total billed charges,48.48% of total billed charges,60.64,90,,48.512,percent of total billed charges,90% of total billed charges,32.67,90,
Finger Splint - Bendable,43601542,CDM,273,RC,Q4049,HCPCS,outpatient,,,13.75,8.25,,8.25,60,,6.6,percent of total billed charges,60% of total billed charges,6.6,48,,5.28,percent of total billed charges,48% of total billed charges,6.88,50,,5.504,percent of total billed charges,50% of total billed charges,6.88,50,,5.504,percent of total billed charges,50% of total billed charges,6.88,50,,5.504,percent of total billed charges,50% of total billed charges,6.88,50,,5.504,percent of total billed charges,50% of total billed charges,9.63,70,,7.704,percent of total billed charges,70% of total billed charges,6.67,48.48,,5.336,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,6.67,48.48,,5.336,percent of total billed charges,48.48% of total billed charges,9.63,70,,7.704,percent of total billed charges,70% of total billed charges,9.63,70,,7.704,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,6.67,48.48,,5.336,percent of total billed charges,48.48% of total billed charges,12.38,90,,9.904,percent of total billed charges,90% of total billed charges,6.67,90,
Post Op Shoe,36039201,CDM,274,RC,L3260,HCPCS,outpatient,,,42.4,25.44,,25.44,60,,20.352,percent of total billed charges,60% of total billed charges,20.35,48,,16.28,percent of total billed charges,48% of total billed charges,21.2,50,,16.96,percent of total billed charges,50% of total billed charges,21.2,50,,16.96,percent of total billed charges,50% of total billed charges,21.2,50,,16.96,percent of total billed charges,50% of total billed charges,21.2,50,,16.96,percent of total billed charges,50% of total billed charges,29.68,70,,23.744,percent of total billed charges,70% of total billed charges,20.56,48.48,,16.448,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,20.56,48.48,,16.448,percent of total billed charges,48.48% of total billed charges,29.68,70,,23.744,percent of total billed charges,70% of total billed charges,29.68,70,,23.744,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,20.56,48.48,,16.448,percent of total billed charges,48.48% of total billed charges,38.16,90,,30.528,percent of total billed charges,90% of total billed charges,20.56,90,
deb bone 20 sq cm/<,44500020,CDM,761,RC,11044,HCPCS,outpatient,,,2825.94,1695.56,,535,100,,,fee schedule,100% of asc tier groupings rate,1356.45,48,,1085.16,percent of total billed charges,48% of total billed charges,2574.32,100,,,fee schedule,100% of bcbs custom fee schedule,2574.32,100,,,fee schedule,100% of bcbs custom fee schedule,2857.5,111,,,fee schedule,111% of bcbs custom fee schedule,1412.97,50,,1130.376,percent of total billed charges,50% of total billed charges,1978.16,70,,1582.528,percent of total billed charges,70% of total billed charges,1370.02,48.48,,1096.016,percent of total billed charges,48.48% of total billed charges,254.09,116.15,,,fee schedule,116.51% of cms physician fee schedule,1370.02,48.48,,1096.016,percent of total billed charges,48.48% of total billed charges,1978.16,70,,1582.528,percent of total billed charges,70% of total billed charges,1978.16,70,,1582.528,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,1370.02,48.48,,1096.016,percent of total billed charges,48.48% of total billed charges,2543.35,90,,2034.68,percent of total billed charges,90% of total billed charges,48.48,2543.35,
DEB BONE ADD ON,44500021,CDM,761,RC,11047,HCPCS,outpatient,,,2825.94,1695.56,,399,100,,,fee schedule,100% of asc tier groupings rate,1356.45,48,,1085.16,percent of total billed charges,48% of total billed charges,1412.97,50,,1130.376,percent of total billed charges,50% of total billed charges,1412.97,50,,1130.376,percent of total billed charges,50% of total billed charges,1412.97,50,,1130.376,percent of total billed charges,50% of total billed charges,1412.97,50,,1130.376,percent of total billed charges,50% of total billed charges,1978.16,70,,1582.528,percent of total billed charges,70% of total billed charges,1370.02,48.48,,1096.016,percent of total billed charges,48.48% of total billed charges,109.8,116.15,,,fee schedule,116.51% of cms physician fee schedule,1370.02,48.48,,1096.016,percent of total billed charges,48.48% of total billed charges,1978.16,70,,1582.528,percent of total billed charges,70% of total billed charges,1978.16,70,,1582.528,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,1370.02,48.48,,1096.016,percent of total billed charges,48.48% of total billed charges,2543.35,90,,2034.68,percent of total billed charges,90% of total billed charges,48.48,2543.35,
Medical Nutrition ; Initial Each 15mins,58450130,CDM,942,RC,97802,HCPCS,outpatient,,,60,36.00,,36,60,,28.8,percent of total billed charges,60% of total billed charges,28.8,48,,23.04,percent of total billed charges,48% of total billed charges,68.69,100,,,fee schedule,100% of bcbs custom fee schedule,68.69,100,,,fee schedule,100% of bcbs custom fee schedule,76.25,111,,,fee schedule,111% of bcbs custom fee schedule,30,50,,24,percent of total billed charges,50% of total billed charges,42,70,,33.6,percent of total billed charges,70% of total billed charges,29.09,48.48,,23.272,percent of total billed charges,48.48% of total billed charges,34.81,116.15,,,fee schedule,116.51% of cms physician fee schedule,29.09,48.48,,23.272,percent of total billed charges,48.48% of total billed charges,42,70,,33.6,percent of total billed charges,70% of total billed charges,42,70,,33.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,29.09,48.48,,23.272,percent of total billed charges,48.48% of total billed charges,54,90,,43.2,percent of total billed charges,90% of total billed charges,29.09,90,
DEBRIDE SKIN & SQ TISSUE,36010007,CDM,761,RC,11042,HCPCS,outpatient,,,676.65,405.99,,535,100,,,fee schedule,100% of asc tier groupings rate,324.79,48,,259.832,percent of total billed charges,48% of total billed charges,849.38,100,,,fee schedule,100% of bcbs custom fee schedule,849.38,100,,,fee schedule,100% of bcbs custom fee schedule,942.81,111,,,fee schedule,111% of bcbs custom fee schedule,338.33,50,,270.664,percent of total billed charges,50% of total billed charges,473.66,70,,378.928,percent of total billed charges,70% of total billed charges,328.04,48.48,,262.432,percent of total billed charges,48.48% of total billed charges,67.48,116.15,,,fee schedule,116.51% of cms physician fee schedule,328.04,48.48,,262.432,percent of total billed charges,48.48% of total billed charges,473.66,70,,378.928,percent of total billed charges,70% of total billed charges,473.66,70,,378.928,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,328.04,48.48,,262.432,percent of total billed charges,48.48% of total billed charges,608.99,90,,487.192,percent of total billed charges,90% of total billed charges,48.48,608.99,
DEB SUBQ TISSUE ADD-ON,44500017,CDM,761,RC,11045,HCPCS,outpatient,,,676.65,405.99,,399,100,,,fee schedule,100% of asc tier groupings rate,324.79,48,,259.832,percent of total billed charges,48% of total billed charges,0.01,100,,,fee schedule,100% of bcbs custom fee schedule,0.01,100,,,fee schedule,100% of bcbs custom fee schedule,0.01,111,,,fee schedule,111% of bcbs custom fee schedule,338.33,50,,270.664,percent of total billed charges,50% of total billed charges,473.66,70,,378.928,percent of total billed charges,70% of total billed charges,328.04,48.48,,262.432,percent of total billed charges,48.48% of total billed charges,28.62,116.15,,,fee schedule,116.51% of cms physician fee schedule,328.04,48.48,,262.432,percent of total billed charges,48.48% of total billed charges,473.66,70,,378.928,percent of total billed charges,70% of total billed charges,473.66,70,,378.928,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,328.04,48.48,,262.432,percent of total billed charges,48.48% of total billed charges,608.99,90,,487.192,percent of total billed charges,90% of total billed charges,48.48,608.99,
Medical Nutrition Group,,,942,RC,97804,HCPCS,outpatient,,,46.3,27.78,,27.78,60,,22.224,percent of total billed charges,60% of total billed charges,22.22,48,,17.776,percent of total billed charges,48% of total billed charges,23.15,50,,18.52,percent of total billed charges,50% of total billed charges,23.15,50,,18.52,percent of total billed charges,50% of total billed charges,23.15,50,,18.52,percent of total billed charges,50% of total billed charges,23.15,50,,18.52,percent of total billed charges,50% of total billed charges,32.41,70,,25.928,percent of total billed charges,70% of total billed charges,22.45,48.48,,17.96,percent of total billed charges,48.48% of total billed charges,16.88,116.15,,,fee schedule,116.51% of cms physician fee schedule,22.45,48.48,,17.96,percent of total billed charges,48.48% of total billed charges,32.41,70,,25.928,percent of total billed charges,70% of total billed charges,32.41,70,,25.928,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,22.45,48.48,,17.96,percent of total billed charges,48.48% of total billed charges,41.67,90,,33.336,percent of total billed charges,90% of total billed charges,22.45,90,
DEB MUSC/FASCIA 20SQ CM/<,44500018,CDM,761,RC,11043,HCPCS,outpatient,,,1286.01,771.61,,535,100,,,fee schedule,100% of asc tier groupings rate,617.28,48,,493.824,percent of total billed charges,48% of total billed charges,1334.19,100,,,fee schedule,100% of bcbs custom fee schedule,1334.19,100,,,fee schedule,100% of bcbs custom fee schedule,1480.95,111,,,fee schedule,111% of bcbs custom fee schedule,643.01,50,,514.408,percent of total billed charges,50% of total billed charges,900.21,70,,720.168,percent of total billed charges,70% of total billed charges,623.46,48.48,,498.768,percent of total billed charges,48.48% of total billed charges,172.2,116.15,,,fee schedule,116.51% of cms physician fee schedule,623.46,48.48,,498.768,percent of total billed charges,48.48% of total billed charges,900.21,70,,720.168,percent of total billed charges,70% of total billed charges,900.21,70,,720.168,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,623.46,48.48,,498.768,percent of total billed charges,48.48% of total billed charges,1157.41,90,,925.928,percent of total billed charges,90% of total billed charges,48.48,1157.41,
DEB MUSC/FASCIA ADD-ON,44500019,CDM,761,RC,11046,HCPCS,outpatient,,,114.58,68.75,,399,100,,,fee schedule,100% of asc tier groupings rate,55,48,,44,percent of total billed charges,48% of total billed charges,57.29,50,,45.832,percent of total billed charges,50% of total billed charges,57.29,50,,45.832,percent of total billed charges,50% of total billed charges,57.29,50,,45.832,percent of total billed charges,50% of total billed charges,57.29,50,,45.832,percent of total billed charges,50% of total billed charges,80.21,70,,64.168,percent of total billed charges,70% of total billed charges,55.55,48.48,,44.44,percent of total billed charges,48.48% of total billed charges,62.11,116.15,,,fee schedule,116.51% of cms physician fee schedule,55.55,48.48,,44.44,percent of total billed charges,48.48% of total billed charges,80.21,70,,64.168,percent of total billed charges,70% of total billed charges,80.21,70,,64.168,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,55.55,48.48,,44.44,percent of total billed charges,48.48% of total billed charges,103.12,90,,82.496,percent of total billed charges,90% of total billed charges,48.48,103.12,
BX SKIN SQ TISS/MM;SINGLE,43601383,CDM,761,RC,11104,HCPCS,outpatient,,,676.65,405.99,,399,100,,,fee schedule,100% of asc tier groupings rate,324.79,48,,259.832,percent of total billed charges,48% of total billed charges,482.21,100,,,fee schedule,100% of bcbs custom fee schedule,482.21,100,,,fee schedule,100% of bcbs custom fee schedule,535.25,111,,,fee schedule,111% of bcbs custom fee schedule,338.33,50,,270.664,percent of total billed charges,50% of total billed charges,473.66,70,,378.928,percent of total billed charges,70% of total billed charges,328.04,48.48,,262.432,percent of total billed charges,48.48% of total billed charges,52.09,116.15,,,fee schedule,116.51% of cms physician fee schedule,328.04,48.48,,262.432,percent of total billed charges,48.48% of total billed charges,473.66,70,,378.928,percent of total billed charges,70% of total billed charges,473.66,70,,378.928,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,328.04,48.48,,262.432,percent of total billed charges,48.48% of total billed charges,608.99,90,,487.192,percent of total billed charges,90% of total billed charges,48.48,608.99,
BX SKIN SQ TISS/MM EA ADD,43601384,CDM,761,RC,11105,HCPCS,outpatient,,,157.81,94.69,,399,100,,,fee schedule,100% of asc tier groupings rate,75.75,48,,60.6,percent of total billed charges,48% of total billed charges,166.76,100,,,fee schedule,100% of bcbs custom fee schedule,166.76,100,,,fee schedule,100% of bcbs custom fee schedule,185.1,111,,,fee schedule,111% of bcbs custom fee schedule,78.91,50,,63.128,percent of total billed charges,50% of total billed charges,110.47,70,,88.376,percent of total billed charges,70% of total billed charges,76.51,48.48,,61.208,percent of total billed charges,48.48% of total billed charges,28.51,116.15,,,fee schedule,116.51% of cms physician fee schedule,76.51,48.48,,61.208,percent of total billed charges,48.48% of total billed charges,110.47,70,,88.376,percent of total billed charges,70% of total billed charges,110.47,70,,88.376,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,76.51,48.48,,61.208,percent of total billed charges,48.48% of total billed charges,142.03,90,,113.624,percent of total billed charges,90% of total billed charges,48.48,142.03,
Removal skin tag +^ 15 LE,36010161,CDM,761,RC,11200,HCPCS,outpatient,,,157.81,94.69,,399,100,,,fee schedule,100% of asc tier groupings rate,75.75,48,,60.6,percent of total billed charges,48% of total billed charges,172.44,100,,,fee schedule,100% of bcbs custom fee schedule,172.44,100,,,fee schedule,100% of bcbs custom fee schedule,191.41,111,,,fee schedule,111% of bcbs custom fee schedule,78.91,50,,63.128,percent of total billed charges,50% of total billed charges,110.47,70,,88.376,percent of total billed charges,70% of total billed charges,76.51,48.48,,61.208,percent of total billed charges,48.48% of total billed charges,83.09,116.15,,,fee schedule,116.51% of cms physician fee schedule,76.51,48.48,,61.208,percent of total billed charges,48.48% of total billed charges,110.47,70,,88.376,percent of total billed charges,70% of total billed charges,110.47,70,,88.376,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,76.51,48.48,,61.208,percent of total billed charges,48.48% of total billed charges,142.03,90,,113.624,percent of total billed charges,90% of total billed charges,48.48,142.03,
ADULT BRIEFS UNDERGARMENTS PK,,,270,RC,,,outpatient,,,18.75,11.25,,11.25,60,,9,percent of total billed charges,60% of total billed charges,9,48,,7.2,percent of total billed charges,48% of total billed charges,9.38,50,,7.504,percent of total billed charges,50% of total billed charges,9.38,50,,7.504,percent of total billed charges,50% of total billed charges,9.38,50,,7.504,percent of total billed charges,50% of total billed charges,9.38,50,,7.504,percent of total billed charges,50% of total billed charges,13.13,70,,10.504,percent of total billed charges,70% of total billed charges,9.09,48.48,,7.272,percent of total billed charges,48.48% of total billed charges,9.09,48.48,,7.272,percent of total billed charges,48.48% of total billed charges,9.09,48.48,,7.272,percent of total billed charges,48.48% of total billed charges,13.13,70,,10.504,percent of total billed charges,70% of total billed charges,13.13,70,,10.504,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.09,48.48,,7.272,percent of total billed charges,48.48% of total billed charges,16.88,90,,13.504,percent of total billed charges,90% of total billed charges,9.09,90,
"EXC ben les .5 < trnk,a,l",43600197,CDM,761,RC,11400,HCPCS,outpatient,,,735.94,441.56,,399,100,,,fee schedule,100% of asc tier groupings rate,353.25,48,,282.6,percent of total billed charges,48% of total billed charges,674.63,100,,,fee schedule,100% of bcbs custom fee schedule,674.63,100,,,fee schedule,100% of bcbs custom fee schedule,748.84,111,,,fee schedule,111% of bcbs custom fee schedule,367.97,50,,294.376,percent of total billed charges,50% of total billed charges,515.16,70,,412.128,percent of total billed charges,70% of total billed charges,356.78,48.48,,285.424,percent of total billed charges,48.48% of total billed charges,91.92,116.15,,,fee schedule,116.51% of cms physician fee schedule,356.78,48.48,,285.424,percent of total billed charges,48.48% of total billed charges,515.16,70,,412.128,percent of total billed charges,70% of total billed charges,515.16,70,,412.128,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,356.78,48.48,,285.424,percent of total billed charges,48.48% of total billed charges,662.35,90,,529.88,percent of total billed charges,90% of total billed charges,48.48,662.35,
EXC B9 LES T/A/L 1.1-2.0,43600199,CDM,761,RC,11402,HCPCS,outpatient,,,735.94,441.56,,399,100,,,fee schedule,100% of asc tier groupings rate,353.25,48,,282.6,percent of total billed charges,48% of total billed charges,674.63,100,,,fee schedule,100% of bcbs custom fee schedule,674.63,100,,,fee schedule,100% of bcbs custom fee schedule,748.84,111,,,fee schedule,111% of bcbs custom fee schedule,367.97,50,,294.376,percent of total billed charges,50% of total billed charges,515.16,70,,412.128,percent of total billed charges,70% of total billed charges,356.78,48.48,,285.424,percent of total billed charges,48.48% of total billed charges,127.11,116.15,,,fee schedule,116.51% of cms physician fee schedule,356.78,48.48,,285.424,percent of total billed charges,48.48% of total billed charges,515.16,70,,412.128,percent of total billed charges,70% of total billed charges,515.16,70,,412.128,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,356.78,48.48,,285.424,percent of total billed charges,48.48% of total billed charges,662.35,90,,529.88,percent of total billed charges,90% of total billed charges,48.48,662.35,
EXC B9 LES S/N/H/F/G .6-1,43600201,CDM,761,RC,11421,HCPCS,outpatient,,,789.06,473.44,,535,100,,,fee schedule,100% of asc tier groupings rate,378.75,48,,303,percent of total billed charges,48% of total billed charges,1128.86,100,,,fee schedule,100% of bcbs custom fee schedule,1128.86,100,,,fee schedule,100% of bcbs custom fee schedule,1253.03,111,,,fee schedule,111% of bcbs custom fee schedule,394.53,50,,315.624,percent of total billed charges,50% of total billed charges,552.34,70,,441.872,percent of total billed charges,70% of total billed charges,382.54,48.48,,306.032,percent of total billed charges,48.48% of total billed charges,120.24,116.15,,,fee schedule,116.51% of cms physician fee schedule,382.54,48.48,,306.032,percent of total billed charges,48.48% of total billed charges,552.34,70,,441.872,percent of total billed charges,70% of total billed charges,552.34,70,,441.872,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,382.54,48.48,,306.032,percent of total billed charges,48.48% of total billed charges,710.15,90,,568.12,percent of total billed charges,90% of total billed charges,48.48,710.15,
EXC B9 LES S/N/H/F/G1.1-2,43600202,CDM,761,RC,11422,HCPCS,outpatient,,,1276.56,765.94,,399,100,,,fee schedule,100% of asc tier groupings rate,612.75,48,,490.2,percent of total billed charges,48% of total billed charges,1128.86,100,,,fee schedule,100% of bcbs custom fee schedule,1128.86,100,,,fee schedule,100% of bcbs custom fee schedule,1253.03,111,,,fee schedule,111% of bcbs custom fee schedule,638.28,50,,510.624,percent of total billed charges,50% of total billed charges,893.59,70,,714.872,percent of total billed charges,70% of total billed charges,618.88,48.48,,495.104,percent of total billed charges,48.48% of total billed charges,149.09,116.15,,,fee schedule,116.51% of cms physician fee schedule,618.88,48.48,,495.104,percent of total billed charges,48.48% of total billed charges,893.59,70,,714.872,percent of total billed charges,70% of total billed charges,893.59,70,,714.872,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,618.88,48.48,,495.104,percent of total billed charges,48.48% of total billed charges,1148.9,90,,919.12,percent of total billed charges,90% of total billed charges,48.48,1148.9,
EXC B9 LES FACE-MM1.1-2.0,43600205,CDM,761,RC,11442,HCPCS,outpatient,,,1281.25,768.75,,399,100,,,fee schedule,100% of asc tier groupings rate,615,48,,492,percent of total billed charges,48% of total billed charges,1128.86,100,,,fee schedule,100% of bcbs custom fee schedule,1128.86,100,,,fee schedule,100% of bcbs custom fee schedule,1253.03,111,,,fee schedule,111% of bcbs custom fee schedule,640.63,50,,512.504,percent of total billed charges,50% of total billed charges,896.88,70,,717.504,percent of total billed charges,70% of total billed charges,621.15,48.48,,496.92,percent of total billed charges,48.48% of total billed charges,161.34,116.15,,,fee schedule,116.51% of cms physician fee schedule,621.15,48.48,,496.92,percent of total billed charges,48.48% of total billed charges,896.88,70,,717.504,percent of total billed charges,70% of total billed charges,896.88,70,,717.504,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,621.15,48.48,,496.92,percent of total billed charges,48.48% of total billed charges,1153.13,90,,922.504,percent of total billed charges,90% of total billed charges,48.48,1153.13,
EXC MAL LES T/A/L 0.6-1.0,43600207,CDM,761,RC,11601,HCPCS,outpatient,,,750,450.00,,399,100,,,fee schedule,100% of asc tier groupings rate,360,48,,288,percent of total billed charges,48% of total billed charges,674.63,100,,,fee schedule,100% of bcbs custom fee schedule,674.63,100,,,fee schedule,100% of bcbs custom fee schedule,748.84,111,,,fee schedule,111% of bcbs custom fee schedule,375,50,,300,percent of total billed charges,50% of total billed charges,525,70,,420,percent of total billed charges,70% of total billed charges,363.6,48.48,,290.88,percent of total billed charges,48.48% of total billed charges,163.23,116.15,,,fee schedule,116.51% of cms physician fee schedule,363.6,48.48,,290.88,percent of total billed charges,48.48% of total billed charges,525,70,,420,percent of total billed charges,70% of total billed charges,525,70,,420,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,363.6,48.48,,290.88,percent of total billed charges,48.48% of total billed charges,675,90,,540,percent of total billed charges,90% of total billed charges,48.48,675,
EXC MAL LES T/A/L 1.1-2.0,43600208,CDM,761,RC,11602,HCPCS,outpatient,,,750,450.00,,399,100,,,fee schedule,100% of asc tier groupings rate,360,48,,288,percent of total billed charges,48% of total billed charges,674.63,100,,,fee schedule,100% of bcbs custom fee schedule,674.63,100,,,fee schedule,100% of bcbs custom fee schedule,748.84,111,,,fee schedule,111% of bcbs custom fee schedule,375,50,,300,percent of total billed charges,50% of total billed charges,525,70,,420,percent of total billed charges,70% of total billed charges,363.6,48.48,,290.88,percent of total billed charges,48.48% of total billed charges,177.06,116.15,,,fee schedule,116.51% of cms physician fee schedule,363.6,48.48,,290.88,percent of total billed charges,48.48% of total billed charges,525,70,,420,percent of total billed charges,70% of total billed charges,525,70,,420,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,363.6,48.48,,290.88,percent of total billed charges,48.48% of total billed charges,675,90,,540,percent of total billed charges,90% of total billed charges,48.48,675,
EXC MAL LES S/N/H/F/G0.5<,43600209,CDM,761,RC,11620,HCPCS,outpatient,,,1328.13,796.88,,399,100,,,fee schedule,100% of asc tier groupings rate,637.5,48,,510,percent of total billed charges,48% of total billed charges,1128.86,100,,,fee schedule,100% of bcbs custom fee schedule,1128.86,100,,,fee schedule,100% of bcbs custom fee schedule,1253.03,111,,,fee schedule,111% of bcbs custom fee schedule,664.07,50,,531.256,percent of total billed charges,50% of total billed charges,929.69,70,,743.752,percent of total billed charges,70% of total billed charges,643.88,48.48,,515.104,percent of total billed charges,48.48% of total billed charges,135.9,116.15,,,fee schedule,116.51% of cms physician fee schedule,643.88,48.48,,515.104,percent of total billed charges,48.48% of total billed charges,929.69,70,,743.752,percent of total billed charges,70% of total billed charges,929.69,70,,743.752,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,643.88,48.48,,515.104,percent of total billed charges,48.48% of total billed charges,1195.32,90,,956.256,percent of total billed charges,90% of total billed charges,48.48,1195.32,
EX MAL LES S/N/H/F/G1.1-2,43600211,CDM,761,RC,11622,HCPCS,outpatient,,,1281.25,768.75,,399,100,,,fee schedule,100% of asc tier groupings rate,615,48,,492,percent of total billed charges,48% of total billed charges,1128.86,100,,,fee schedule,100% of bcbs custom fee schedule,1128.86,100,,,fee schedule,100% of bcbs custom fee schedule,1253.03,111,,,fee schedule,111% of bcbs custom fee schedule,640.63,50,,512.504,percent of total billed charges,50% of total billed charges,896.88,70,,717.504,percent of total billed charges,70% of total billed charges,621.15,48.48,,496.92,percent of total billed charges,48.48% of total billed charges,186.27,116.15,,,fee schedule,116.51% of cms physician fee schedule,621.15,48.48,,496.92,percent of total billed charges,48.48% of total billed charges,896.88,70,,717.504,percent of total billed charges,70% of total billed charges,896.88,70,,717.504,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,621.15,48.48,,496.92,percent of total billed charges,48.48% of total billed charges,1153.13,90,,922.504,percent of total billed charges,90% of total billed charges,48.48,1153.13,
AVUL NP PAR/CMPL SNGL/SMP,36010009,CDM,761,RC,11730,HCPCS,outpatient,,,202.28,121.37,,399,100,,,fee schedule,100% of asc tier groupings rate,97.09,48,,77.672,percent of total billed charges,48% of total billed charges,172.44,100,,,fee schedule,100% of bcbs custom fee schedule,172.44,100,,,fee schedule,100% of bcbs custom fee schedule,191.41,111,,,fee schedule,111% of bcbs custom fee schedule,101.14,50,,80.912,percent of total billed charges,50% of total billed charges,141.6,70,,113.28,percent of total billed charges,70% of total billed charges,98.07,48.48,,78.456,percent of total billed charges,48.48% of total billed charges,60.15,116.15,,,fee schedule,116.51% of cms physician fee schedule,98.07,48.48,,78.456,percent of total billed charges,48.48% of total billed charges,141.6,70,,113.28,percent of total billed charges,70% of total billed charges,141.6,70,,113.28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,98.07,48.48,,78.456,percent of total billed charges,48.48% of total billed charges,182.05,90,,145.64,percent of total billed charges,90% of total billed charges,48.48,182.05,
"AVUL NP, PAR/CMPL EA+",36011045,CDM,761,RC,11732,HCPCS,outpatient,,,157.81,94.69,,399,100,,,fee schedule,100% of asc tier groupings rate,75.75,48,,60.6,percent of total billed charges,48% of total billed charges,137.87,100,,,fee schedule,100% of bcbs custom fee schedule,137.87,100,,,fee schedule,100% of bcbs custom fee schedule,153.04,111,,,fee schedule,111% of bcbs custom fee schedule,78.91,50,,63.128,percent of total billed charges,50% of total billed charges,110.47,70,,88.376,percent of total billed charges,70% of total billed charges,76.51,48.48,,61.208,percent of total billed charges,48.48% of total billed charges,19.06,116.15,,,fee schedule,116.51% of cms physician fee schedule,76.51,48.48,,61.208,percent of total billed charges,48.48% of total billed charges,110.47,70,,88.376,percent of total billed charges,70% of total billed charges,110.47,70,,88.376,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,76.51,48.48,,61.208,percent of total billed charges,48.48% of total billed charges,142.03,90,,113.624,percent of total billed charges,90% of total billed charges,48.48,142.03,
I&D FINGER ABSCESS; COMP,36010274,CDM,761,RC,26011,HCPCS,outpatient,,,567.6,340.56,,399,100,,,fee schedule,100% of asc tier groupings rate,272.45,48,,217.96,percent of total billed charges,48% of total billed charges,1898.23,100,,,fee schedule,100% of bcbs custom fee schedule,1898.23,100,,,fee schedule,100% of bcbs custom fee schedule,2107.04,111,,,fee schedule,111% of bcbs custom fee schedule,283.8,50,,227.04,percent of total billed charges,50% of total billed charges,397.32,70,,317.856,percent of total billed charges,70% of total billed charges,275.17,48.48,,220.136,percent of total billed charges,48.48% of total billed charges,205.67,116.15,,,fee schedule,116.51% of cms physician fee schedule,275.17,48.48,,220.136,percent of total billed charges,48.48% of total billed charges,397.32,70,,317.856,percent of total billed charges,70% of total billed charges,397.32,70,,317.856,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,275.17,48.48,,220.136,percent of total billed charges,48.48% of total billed charges,510.84,90,,408.672,percent of total billed charges,90% of total billed charges,48.48,510.84,
EXC NAIL BED PAR/COM,36010011,CDM,761,RC,11750,HCPCS,outpatient,,,750,450.00,,399,100,,,fee schedule,100% of asc tier groupings rate,360,48,,288,percent of total billed charges,48% of total billed charges,674.63,100,,,fee schedule,100% of bcbs custom fee schedule,674.63,100,,,fee schedule,100% of bcbs custom fee schedule,748.84,111,,,fee schedule,111% of bcbs custom fee schedule,375,50,,300,percent of total billed charges,50% of total billed charges,525,70,,420,percent of total billed charges,70% of total billed charges,363.6,48.48,,290.88,percent of total billed charges,48.48% of total billed charges,112.56,116.15,,,fee schedule,116.51% of cms physician fee schedule,363.6,48.48,,290.88,percent of total billed charges,48.48% of total billed charges,525,70,,420,percent of total billed charges,70% of total billed charges,525,70,,420,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,363.6,48.48,,290.88,percent of total billed charges,48.48% of total billed charges,675,90,,540,percent of total billed charges,90% of total billed charges,48.48,675,
BIOPSY OF NAIL UNIT,43701726,CDM,761,RC,11755,HCPCS,outpatient,,,1060.99,636.59,,399,100,,,fee schedule,100% of asc tier groupings rate,509.28,48,,407.424,percent of total billed charges,48% of total billed charges,674.63,100,,,fee schedule,100% of bcbs custom fee schedule,674.63,100,,,fee schedule,100% of bcbs custom fee schedule,748.84,111,,,fee schedule,111% of bcbs custom fee schedule,530.5,50,,424.4,percent of total billed charges,50% of total billed charges,742.69,70,,594.152,percent of total billed charges,70% of total billed charges,514.37,48.48,,411.496,percent of total billed charges,48.48% of total billed charges,67.98,116.15,,,fee schedule,116.51% of cms physician fee schedule,514.37,48.48,,411.496,percent of total billed charges,48.48% of total billed charges,742.69,70,,594.152,percent of total billed charges,70% of total billed charges,742.69,70,,594.152,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,514.37,48.48,,411.496,percent of total billed charges,48.48% of total billed charges,954.89,90,,763.912,percent of total billed charges,90% of total billed charges,48.48,954.89,
SHAVE SKN LES <.5,43601387,CDM,761,RC,11300,HCPCS,outpatient,,,250.75,150.45,,150.45,60,,120.36,percent of total billed charges,60% of total billed charges,120.36,48,,96.288,percent of total billed charges,48% of total billed charges,137.87,100,,,fee schedule,100% of bcbs custom fee schedule,137.87,100,,,fee schedule,100% of bcbs custom fee schedule,153.04,111,,,fee schedule,111% of bcbs custom fee schedule,125.38,50,,100.304,percent of total billed charges,50% of total billed charges,175.53,70,,140.424,percent of total billed charges,70% of total billed charges,121.56,48.48,,97.248,percent of total billed charges,48.48% of total billed charges,37.81,116.15,,,fee schedule,116.51% of cms physician fee schedule,121.56,48.48,,97.248,percent of total billed charges,48.48% of total billed charges,175.53,70,,140.424,percent of total billed charges,70% of total billed charges,175.53,70,,140.424,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,121.56,48.48,,97.248,percent of total billed charges,48.48% of total billed charges,225.68,90,,180.544,percent of total billed charges,90% of total billed charges,48.48,225.68,
DEBRDE P-THCK BRN SMALL,36010026,CDM,761,RC,16020,HCPCS,outpatient,,,112.66,67.60,,399,100,,,fee schedule,100% of asc tier groupings rate,54.08,48,,43.264,percent of total billed charges,48% of total billed charges,322.02,100,,,fee schedule,100% of bcbs custom fee schedule,322.02,100,,,fee schedule,100% of bcbs custom fee schedule,357.44,111,,,fee schedule,111% of bcbs custom fee schedule,56.33,50,,45.064,percent of total billed charges,50% of total billed charges,78.86,70,,63.088,percent of total billed charges,70% of total billed charges,54.62,48.48,,43.696,percent of total billed charges,48.48% of total billed charges,61.54,116.15,,,fee schedule,116.51% of cms physician fee schedule,54.62,48.48,,43.696,percent of total billed charges,48.48% of total billed charges,78.86,70,,63.088,percent of total billed charges,70% of total billed charges,78.86,70,,63.088,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,54.62,48.48,,43.696,percent of total billed charges,48.48% of total billed charges,101.39,90,,81.112,percent of total billed charges,90% of total billed charges,48.48,101.39,
CHEMICAL CAUTERY TISSUE,36010260,CDM,761,RC,17250,HCPCS,outpatient,,,353.49,212.09,,399,100,,,fee schedule,100% of asc tier groupings rate,169.68,48,,135.744,percent of total billed charges,48% of total billed charges,172.44,100,,,fee schedule,100% of bcbs custom fee schedule,172.44,100,,,fee schedule,100% of bcbs custom fee schedule,191.41,111,,,fee schedule,111% of bcbs custom fee schedule,176.75,50,,141.4,percent of total billed charges,50% of total billed charges,247.44,70,,197.952,percent of total billed charges,70% of total billed charges,171.37,48.48,,137.096,percent of total billed charges,48.48% of total billed charges,41.49,116.15,,,fee schedule,116.51% of cms physician fee schedule,171.37,48.48,,137.096,percent of total billed charges,48.48% of total billed charges,247.44,70,,197.952,percent of total billed charges,70% of total billed charges,247.44,70,,197.952,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,171.37,48.48,,137.096,percent of total billed charges,48.48% of total billed charges,318.14,90,,254.512,percent of total billed charges,90% of total billed charges,48.48,318.14,
DEBRDE P-THCK BRN MEDIUM,36010027,CDM,761,RC,16025,HCPCS,outpatient,,,326.56,195.94,,535,100,,,fee schedule,100% of asc tier groupings rate,156.75,48,,125.4,percent of total billed charges,48% of total billed charges,163.28,50,,130.624,percent of total billed charges,50% of total billed charges,163.28,50,,130.624,percent of total billed charges,50% of total billed charges,163.28,50,,130.624,percent of total billed charges,50% of total billed charges,163.28,50,,130.624,percent of total billed charges,50% of total billed charges,228.59,70,,182.872,percent of total billed charges,70% of total billed charges,158.32,48.48,,126.656,percent of total billed charges,48.48% of total billed charges,124.47,116.15,,,fee schedule,116.51% of cms physician fee schedule,158.32,48.48,,126.656,percent of total billed charges,48.48% of total billed charges,228.59,70,,182.872,percent of total billed charges,70% of total billed charges,228.59,70,,182.872,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,158.32,48.48,,126.656,percent of total billed charges,48.48% of total billed charges,293.9,90,,235.12,percent of total billed charges,90% of total billed charges,48.48,293.9,
INPATIENT WOUND VAC PER DAY,44500005,CDM,279,RC,97606,HCPCS,outpatient,,,353.49,212.09,,212.09,60,,169.672,percent of total billed charges,60% of total billed charges,169.68,48,,135.744,percent of total billed charges,48% of total billed charges,172.45,100,,,fee schedule,100% of bcbs custom fee schedule,172.45,100,,,fee schedule,100% of bcbs custom fee schedule,191.42,111,,,fee schedule,111% of bcbs custom fee schedule,176.75,50,,141.4,percent of total billed charges,50% of total billed charges,247.44,70,,197.952,percent of total billed charges,70% of total billed charges,171.37,48.48,,137.096,percent of total billed charges,48.48% of total billed charges,29.73,116.15,,,fee schedule,116.51% of cms physician fee schedule,171.37,48.48,,137.096,percent of total billed charges,48.48% of total billed charges,247.44,70,,197.952,percent of total billed charges,70% of total billed charges,247.44,70,,197.952,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,171.37,48.48,,137.096,percent of total billed charges,48.48% of total billed charges,318.14,90,,254.512,percent of total billed charges,90% of total billed charges,48.48,318.14,
DESTR PRE-MAL LES 1ST LES,43601127,CDM,761,RC,17000,HCPCS,outpatient,,,225,135.00,,399,100,,,fee schedule,100% of asc tier groupings rate,108,48,,86.4,percent of total billed charges,48% of total billed charges,96.33,100,,,fee schedule,100% of bcbs custom fee schedule,96.33,100,,,fee schedule,100% of bcbs custom fee schedule,106.93,111,,,fee schedule,111% of bcbs custom fee schedule,112.5,50,,90,percent of total billed charges,50% of total billed charges,157.5,70,,126,percent of total billed charges,70% of total billed charges,109.08,48.48,,87.264,percent of total billed charges,48.48% of total billed charges,59.76,116.15,,,fee schedule,116.51% of cms physician fee schedule,109.08,48.48,,87.264,percent of total billed charges,48.48% of total billed charges,157.5,70,,126,percent of total billed charges,70% of total billed charges,157.5,70,,126,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,109.08,48.48,,87.264,percent of total billed charges,48.48% of total billed charges,202.5,90,,162,percent of total billed charges,90% of total billed charges,48.48,202.5,
DESTRU B9 LESION UP TO 14,43601152,CDM,761,RC,17110,HCPCS,outpatient,,,273.44,164.06,,399,100,,,fee schedule,100% of asc tier groupings rate,131.25,48,,105,percent of total billed charges,48% of total billed charges,172.44,100,,,fee schedule,100% of bcbs custom fee schedule,172.44,100,,,fee schedule,100% of bcbs custom fee schedule,191.41,111,,,fee schedule,111% of bcbs custom fee schedule,136.72,50,,109.376,percent of total billed charges,50% of total billed charges,191.41,70,,153.128,percent of total billed charges,70% of total billed charges,132.56,48.48,,106.048,percent of total billed charges,48.48% of total billed charges,74.19,116.15,,,fee schedule,116.51% of cms physician fee schedule,132.56,48.48,,106.048,percent of total billed charges,48.48% of total billed charges,191.41,70,,153.128,percent of total billed charges,70% of total billed charges,191.41,70,,153.128,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,132.56,48.48,,106.048,percent of total billed charges,48.48% of total billed charges,246.1,90,,196.88,percent of total billed charges,90% of total billed charges,48.48,246.1,
INJ(s) TRIGGR PNT 1-2 MUS,43701661,CDM,761,RC,20552,HCPCS,outpatient,,,513.44,308.06,,399,100,,,fee schedule,100% of asc tier groupings rate,246.45,48,,197.16,percent of total billed charges,48% of total billed charges,368.64,100,,,fee schedule,100% of bcbs custom fee schedule,368.64,100,,,fee schedule,100% of bcbs custom fee schedule,409.19,111,,,fee schedule,111% of bcbs custom fee schedule,256.72,50,,205.376,percent of total billed charges,50% of total billed charges,359.41,70,,287.528,percent of total billed charges,70% of total billed charges,248.92,48.48,,199.136,percent of total billed charges,48.48% of total billed charges,41.24,116.15,,,fee schedule,116.51% of cms physician fee schedule,248.92,48.48,,199.136,percent of total billed charges,48.48% of total billed charges,359.41,70,,287.528,percent of total billed charges,70% of total billed charges,359.41,70,,287.528,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,248.92,48.48,,199.136,percent of total billed charges,48.48% of total billed charges,462.1,90,,369.68,percent of total billed charges,90% of total billed charges,48.48,462.1,
DRAIN/INJECT SM JNT/BURSA,36010163,CDM,761,RC,20600,HCPCS,outpatient,,,560.94,336.56,,399,100,,,fee schedule,100% of asc tier groupings rate,269.25,48,,215.4,percent of total billed charges,48% of total billed charges,368.64,100,,,fee schedule,100% of bcbs custom fee schedule,368.64,100,,,fee schedule,100% of bcbs custom fee schedule,409.19,111,,,fee schedule,111% of bcbs custom fee schedule,280.47,50,,224.376,percent of total billed charges,50% of total billed charges,392.66,70,,314.128,percent of total billed charges,70% of total billed charges,271.94,48.48,,217.552,percent of total billed charges,48.48% of total billed charges,40.33,116.15,,,fee schedule,116.51% of cms physician fee schedule,271.94,48.48,,217.552,percent of total billed charges,48.48% of total billed charges,392.66,70,,314.128,percent of total billed charges,70% of total billed charges,392.66,70,,314.128,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,271.94,48.48,,217.552,percent of total billed charges,48.48% of total billed charges,504.85,90,,403.88,percent of total billed charges,90% of total billed charges,48.48,504.85,
DRAIN/INJ INTERM JNT/BURS,36010143,CDM,761,RC,20605,HCPCS,outpatient,,,560.94,336.56,,399,100,,,fee schedule,100% of asc tier groupings rate,269.25,48,,215.4,percent of total billed charges,48% of total billed charges,368.64,100,,,fee schedule,100% of bcbs custom fee schedule,368.64,100,,,fee schedule,100% of bcbs custom fee schedule,409.19,111,,,fee schedule,111% of bcbs custom fee schedule,280.47,50,,224.376,percent of total billed charges,50% of total billed charges,392.66,70,,314.128,percent of total billed charges,70% of total billed charges,271.94,48.48,,217.552,percent of total billed charges,48.48% of total billed charges,41.44,116.15,,,fee schedule,116.51% of cms physician fee schedule,271.94,48.48,,217.552,percent of total billed charges,48.48% of total billed charges,392.66,70,,314.128,percent of total billed charges,70% of total billed charges,392.66,70,,314.128,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,271.94,48.48,,217.552,percent of total billed charges,48.48% of total billed charges,504.85,90,,403.88,percent of total billed charges,90% of total billed charges,48.48,504.85,
Inj/Asp Major Joint,35010107,CDM,761,RC,20610,HCPCS,outpatient,,,560.94,336.56,,399,100,,,fee schedule,100% of asc tier groupings rate,269.25,48,,215.4,percent of total billed charges,48% of total billed charges,368.64,100,,,fee schedule,100% of bcbs custom fee schedule,368.64,100,,,fee schedule,100% of bcbs custom fee schedule,409.19,111,,,fee schedule,111% of bcbs custom fee schedule,280.47,50,,224.376,percent of total billed charges,50% of total billed charges,392.66,70,,314.128,percent of total billed charges,70% of total billed charges,271.94,48.48,,217.552,percent of total billed charges,48.48% of total billed charges,51.19,116.15,,,fee schedule,116.51% of cms physician fee schedule,271.94,48.48,,217.552,percent of total billed charges,48.48% of total billed charges,392.66,70,,314.128,percent of total billed charges,70% of total billed charges,392.66,70,,314.128,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,271.94,48.48,,217.552,percent of total billed charges,48.48% of total billed charges,504.85,90,,403.88,percent of total billed charges,90% of total billed charges,48.48,504.85,
ASP/INJ GANGLION ANY SITE,36011052,CDM,761,RC,20612,HCPCS,outpatient,,,513.44,308.06,,399,100,,,fee schedule,100% of asc tier groupings rate,246.45,48,,197.16,percent of total billed charges,48% of total billed charges,368.64,100,,,fee schedule,100% of bcbs custom fee schedule,368.64,100,,,fee schedule,100% of bcbs custom fee schedule,409.19,111,,,fee schedule,111% of bcbs custom fee schedule,256.72,50,,205.376,percent of total billed charges,50% of total billed charges,359.41,70,,287.528,percent of total billed charges,70% of total billed charges,248.92,48.48,,199.136,percent of total billed charges,48.48% of total billed charges,46.04,116.15,,,fee schedule,116.51% of cms physician fee schedule,248.92,48.48,,199.136,percent of total billed charges,48.48% of total billed charges,359.41,70,,287.528,percent of total billed charges,70% of total billed charges,359.41,70,,287.528,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,248.92,48.48,,199.136,percent of total billed charges,48.48% of total billed charges,462.1,90,,369.68,percent of total billed charges,90% of total billed charges,48.48,462.1,
ARTHROTOMY IP JOINT,,,761,RC,26080,HCPCS,outpatient,,,2175,1305.00,,756,100,,,fee schedule,100% of asc tier groupings rate,1044,48,,835.2,percent of total billed charges,48% of total billed charges,2543.57,100,,,fee schedule,100% of bcbs custom fee schedule,2543.57,100,,,fee schedule,100% of bcbs custom fee schedule,2823.36,111,,,fee schedule,111% of bcbs custom fee schedule,1087.5,50,,870,percent of total billed charges,50% of total billed charges,1522.5,70,,1218,percent of total billed charges,70% of total billed charges,1054.44,48.48,,843.552,percent of total billed charges,48.48% of total billed charges,446.48,116.15,,,fee schedule,116.51% of cms physician fee schedule,1054.44,48.48,,843.552,percent of total billed charges,48.48% of total billed charges,1522.5,70,,1218,percent of total billed charges,70% of total billed charges,1522.5,70,,1218,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,1054.44,48.48,,843.552,percent of total billed charges,48.48% of total billed charges,1957.5,90,,1566,percent of total billed charges,90% of total billed charges,48.48,1957.5,
INC THROMB HEMORRHOID EXT,36010187,CDM,761,RC,46083,HCPCS,outpatient,,,265.63,159.38,,399,100,,,fee schedule,100% of asc tier groupings rate,127.5,48,,102,percent of total billed charges,48% of total billed charges,569.99,100,,,fee schedule,100% of bcbs custom fee schedule,569.99,100,,,fee schedule,100% of bcbs custom fee schedule,632.69,111,,,fee schedule,111% of bcbs custom fee schedule,132.82,50,,106.256,percent of total billed charges,50% of total billed charges,185.94,70,,148.752,percent of total billed charges,70% of total billed charges,128.78,48.48,,103.024,percent of total billed charges,48.48% of total billed charges,122.53,116.15,,,fee schedule,116.51% of cms physician fee schedule,128.78,48.48,,103.024,percent of total billed charges,48.48% of total billed charges,185.94,70,,148.752,percent of total billed charges,70% of total billed charges,185.94,70,,148.752,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,128.78,48.48,,103.024,percent of total billed charges,48.48% of total billed charges,239.07,90,,191.256,percent of total billed charges,90% of total billed charges,48.48,239.07,
DRAINAGE OF SCROTAL ABCES,36010190,CDM,761,RC,55100,HCPCS,outpatient,,,2600.1,1560.06,,399,100,,,fee schedule,100% of asc tier groupings rate,1248.05,48,,998.44,percent of total billed charges,48% of total billed charges,2650.21,100,,,fee schedule,100% of bcbs custom fee schedule,2650.21,100,,,fee schedule,100% of bcbs custom fee schedule,2941.73,111,,,fee schedule,111% of bcbs custom fee schedule,1300.05,50,,1040.04,percent of total billed charges,50% of total billed charges,1820.07,70,,1456.056,percent of total billed charges,70% of total billed charges,1260.53,48.48,,1008.424,percent of total billed charges,48.48% of total billed charges,187.19,116.15,,,fee schedule,116.51% of cms physician fee schedule,1260.53,48.48,,1008.424,percent of total billed charges,48.48% of total billed charges,1820.07,70,,1456.056,percent of total billed charges,70% of total billed charges,1820.07,70,,1456.056,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,1260.53,48.48,,1008.424,percent of total billed charges,48.48% of total billed charges,2340.09,90,,1872.072,percent of total billed charges,90% of total billed charges,48.48,2340.09,
I&D PERINEAL/VULVA ABSCES,36010225,CDM,761,RC,56405,HCPCS,outpatient,,,542.19,325.31,,535,100,,,fee schedule,100% of asc tier groupings rate,260.25,48,,208.2,percent of total billed charges,48% of total billed charges,387.17,100,,,fee schedule,100% of bcbs custom fee schedule,387.17,100,,,fee schedule,100% of bcbs custom fee schedule,429.76,111,,,fee schedule,111% of bcbs custom fee schedule,271.1,50,,216.88,percent of total billed charges,50% of total billed charges,379.53,70,,303.624,percent of total billed charges,70% of total billed charges,262.85,48.48,,210.28,percent of total billed charges,48.48% of total billed charges,140.12,116.15,,,fee schedule,116.51% of cms physician fee schedule,262.85,48.48,,210.28,percent of total billed charges,48.48% of total billed charges,379.53,70,,303.624,percent of total billed charges,70% of total billed charges,379.53,70,,303.624,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,262.85,48.48,,210.28,percent of total billed charges,48.48% of total billed charges,487.97,90,,390.376,percent of total billed charges,90% of total billed charges,48.48,487.97,
BLEPHAROTOMY,36010272,CDM,761,RC,67700,HCPCS,outpatient,,,507.81,304.69,,399,100,,,fee schedule,100% of asc tier groupings rate,243.75,48,,195,percent of total billed charges,48% of total billed charges,423.34,100,,,fee schedule,100% of bcbs custom fee schedule,423.34,100,,,fee schedule,100% of bcbs custom fee schedule,469.91,111,,,fee schedule,111% of bcbs custom fee schedule,253.91,50,,203.128,percent of total billed charges,50% of total billed charges,355.47,70,,284.376,percent of total billed charges,70% of total billed charges,246.19,48.48,,196.952,percent of total billed charges,48.48% of total billed charges,125.37,116.15,,,fee schedule,116.51% of cms physician fee schedule,246.19,48.48,,196.952,percent of total billed charges,48.48% of total billed charges,355.47,70,,284.376,percent of total billed charges,70% of total billed charges,355.47,70,,284.376,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,246.19,48.48,,196.952,percent of total billed charges,48.48% of total billed charges,457.03,90,,365.624,percent of total billed charges,90% of total billed charges,48.48,457.03,
BX UTERINE LINING,43601167,CDM,761,RC,58100,HCPCS,outpatient,,,315.63,189.38,,399,100,,,fee schedule,100% of asc tier groupings rate,151.5,48,,121.2,percent of total billed charges,48% of total billed charges,205.15,100,,,fee schedule,100% of bcbs custom fee schedule,205.15,100,,,fee schedule,100% of bcbs custom fee schedule,227.72,111,,,fee schedule,111% of bcbs custom fee schedule,157.82,50,,126.256,percent of total billed charges,50% of total billed charges,220.94,70,,176.752,percent of total billed charges,70% of total billed charges,153.02,48.48,,122.416,percent of total billed charges,48.48% of total billed charges,71.89,116.15,,,fee schedule,116.51% of cms physician fee schedule,153.02,48.48,,122.416,percent of total billed charges,48.48% of total billed charges,220.94,70,,176.752,percent of total billed charges,70% of total billed charges,220.94,70,,176.752,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,153.02,48.48,,122.416,percent of total billed charges,48.48% of total billed charges,284.07,90,,227.256,percent of total billed charges,90% of total billed charges,48.48,284.07,
CMPLX RPR F/C/C/M/N/AX/G/H/F;2.6-7.5,36010186,CDM,761,RC,13132,HCPCS,outpatient,,,860.94,516.56,,612,100,,,fee schedule,100% of asc tier groupings rate,413.25,48,,330.6,percent of total billed charges,48% of total billed charges,1171.5,100,,,fee schedule,100% of bcbs custom fee schedule,1171.5,100,,,fee schedule,100% of bcbs custom fee schedule,1300.37,111,,,fee schedule,111% of bcbs custom fee schedule,430.47,50,,344.376,percent of total billed charges,50% of total billed charges,602.66,70,,482.128,percent of total billed charges,70% of total billed charges,417.38,48.48,,333.904,percent of total billed charges,48.48% of total billed charges,333.43,116.15,,,fee schedule,116.51% of cms physician fee schedule,417.38,48.48,,333.904,percent of total billed charges,48.48% of total billed charges,602.66,70,,482.128,percent of total billed charges,70% of total billed charges,602.66,70,,482.128,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,417.38,48.48,,333.904,percent of total billed charges,48.48% of total billed charges,774.85,90,,619.88,percent of total billed charges,90% of total billed charges,48.48,774.85,
CMPLX RPR F/C/C/M/N/AX/G/H/F;2.6-7.5,36010186,CDM,450,RC,13132,HCPCS,outpatient,,,860.94,516.56,,612,100,,,fee schedule,100% of asc tier groupings rate,413.25,48,,330.6,percent of total billed charges,48% of total billed charges,1171.5,100,,,fee schedule,100% of bcbs custom fee schedule,1171.5,100,,,fee schedule,100% of bcbs custom fee schedule,1300.37,111,,,fee schedule,111% of bcbs custom fee schedule,430.47,50,,344.376,percent of total billed charges,50% of total billed charges,602.66,70,,482.128,percent of total billed charges,70% of total billed charges,417.38,48.48,,333.904,percent of total billed charges,48.48% of total billed charges,333.43,116.15,,,fee schedule,116.51% of cms physician fee schedule,417.38,48.48,,333.904,percent of total billed charges,48.48% of total billed charges,602.66,70,,482.128,percent of total billed charges,70% of total billed charges,602.66,70,,482.128,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,417.38,48.48,,333.904,percent of total billed charges,48.48% of total billed charges,774.85,90,,619.88,percent of total billed charges,90% of total billed charges,48.48,774.85,
"CATHETER,, URINE SPECIMEN COLLECT",,,270,RC,,,outpatient,,,21.78,13.07,,13.07,60,,10.456,percent of total billed charges,60% of total billed charges,10.45,48,,8.36,percent of total billed charges,48% of total billed charges,10.89,50,,8.712,percent of total billed charges,50% of total billed charges,10.89,50,,8.712,percent of total billed charges,50% of total billed charges,10.89,50,,8.712,percent of total billed charges,50% of total billed charges,10.89,50,,8.712,percent of total billed charges,50% of total billed charges,15.25,70,,12.2,percent of total billed charges,70% of total billed charges,10.56,48.48,,8.448,percent of total billed charges,48.48% of total billed charges,10.56,48.48,,8.448,percent of total billed charges,48.48% of total billed charges,10.56,48.48,,8.448,percent of total billed charges,48.48% of total billed charges,15.25,70,,12.2,percent of total billed charges,70% of total billed charges,15.25,70,,12.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,10.56,48.48,,8.448,percent of total billed charges,48.48% of total billed charges,19.6,90,,15.68,percent of total billed charges,90% of total billed charges,10.56,90,
"BRACE, ANKLE, AIR GEL, 9 IN MEDIUM",,,273,RC,,,outpatient,,,44.94,26.96,,26.96,60,,21.568,percent of total billed charges,60% of total billed charges,21.57,48,,17.256,percent of total billed charges,48% of total billed charges,22.47,50,,17.976,percent of total billed charges,50% of total billed charges,22.47,50,,17.976,percent of total billed charges,50% of total billed charges,22.47,50,,17.976,percent of total billed charges,50% of total billed charges,22.47,50,,17.976,percent of total billed charges,50% of total billed charges,31.46,70,,25.168,percent of total billed charges,70% of total billed charges,21.79,48.48,,17.432,percent of total billed charges,48.48% of total billed charges,21.79,48.48,,17.432,percent of total billed charges,48.48% of total billed charges,21.79,48.48,,17.432,percent of total billed charges,48.48% of total billed charges,31.46,70,,25.168,percent of total billed charges,70% of total billed charges,31.46,70,,25.168,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,21.79,48.48,,17.432,percent of total billed charges,48.48% of total billed charges,40.45,90,,32.36,percent of total billed charges,90% of total billed charges,21.79,90,
"BRACE, ANKLE, AIR GEL, 10 IN, REGULAR",,,273,RC,,,outpatient,,,44.94,26.96,,26.96,60,,21.568,percent of total billed charges,60% of total billed charges,21.57,48,,17.256,percent of total billed charges,48% of total billed charges,22.47,50,,17.976,percent of total billed charges,50% of total billed charges,22.47,50,,17.976,percent of total billed charges,50% of total billed charges,22.47,50,,17.976,percent of total billed charges,50% of total billed charges,22.47,50,,17.976,percent of total billed charges,50% of total billed charges,31.46,70,,25.168,percent of total billed charges,70% of total billed charges,21.79,48.48,,17.432,percent of total billed charges,48.48% of total billed charges,21.79,48.48,,17.432,percent of total billed charges,48.48% of total billed charges,21.79,48.48,,17.432,percent of total billed charges,48.48% of total billed charges,31.46,70,,25.168,percent of total billed charges,70% of total billed charges,31.46,70,,25.168,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,21.79,48.48,,17.432,percent of total billed charges,48.48% of total billed charges,40.45,90,,32.36,percent of total billed charges,90% of total billed charges,21.79,90,
"BRACE, ANKLE, AIR GEL, 8 IN, SMALL",,,273,RC,,,outpatient,,,45.78,27.47,,27.47,60,,21.976,percent of total billed charges,60% of total billed charges,21.97,48,,17.576,percent of total billed charges,48% of total billed charges,22.89,50,,18.312,percent of total billed charges,50% of total billed charges,22.89,50,,18.312,percent of total billed charges,50% of total billed charges,22.89,50,,18.312,percent of total billed charges,50% of total billed charges,22.89,50,,18.312,percent of total billed charges,50% of total billed charges,32.05,70,,25.64,percent of total billed charges,70% of total billed charges,22.19,48.48,,17.752,percent of total billed charges,48.48% of total billed charges,22.19,48.48,,17.752,percent of total billed charges,48.48% of total billed charges,22.19,48.48,,17.752,percent of total billed charges,48.48% of total billed charges,32.05,70,,25.64,percent of total billed charges,70% of total billed charges,32.05,70,,25.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,22.19,48.48,,17.752,percent of total billed charges,48.48% of total billed charges,41.2,90,,32.96,percent of total billed charges,90% of total billed charges,22.19,90,
EYE CARE SUPPLIES,,,270,RC,,,outpatient,,,42.35,25.41,,25.41,60,,20.328,percent of total billed charges,60% of total billed charges,20.33,48,,16.264,percent of total billed charges,48% of total billed charges,21.18,50,,16.944,percent of total billed charges,50% of total billed charges,21.18,50,,16.944,percent of total billed charges,50% of total billed charges,21.18,50,,16.944,percent of total billed charges,50% of total billed charges,21.18,50,,16.944,percent of total billed charges,50% of total billed charges,29.65,70,,23.72,percent of total billed charges,70% of total billed charges,20.53,48.48,,16.424,percent of total billed charges,48.48% of total billed charges,20.53,48.48,,16.424,percent of total billed charges,48.48% of total billed charges,20.53,48.48,,16.424,percent of total billed charges,48.48% of total billed charges,29.65,70,,23.72,percent of total billed charges,70% of total billed charges,29.65,70,,23.72,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,20.53,48.48,,16.424,percent of total billed charges,48.48% of total billed charges,38.12,90,,30.496,percent of total billed charges,90% of total billed charges,20.53,90,
Pelvic Binder,,,270,RC,L2580,HCPCS,outpatient,,,324.6,194.76,,194.76,60,,155.808,percent of total billed charges,60% of total billed charges,155.81,48,,124.648,percent of total billed charges,48% of total billed charges,162.3,50,,129.84,percent of total billed charges,50% of total billed charges,162.3,50,,129.84,percent of total billed charges,50% of total billed charges,162.3,50,,129.84,percent of total billed charges,50% of total billed charges,162.3,50,,129.84,percent of total billed charges,50% of total billed charges,227.22,70,,181.776,percent of total billed charges,70% of total billed charges,157.37,48.48,,125.896,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,157.37,48.48,,125.896,percent of total billed charges,48.48% of total billed charges,227.22,70,,181.776,percent of total billed charges,70% of total billed charges,227.22,70,,181.776,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,157.37,48.48,,125.896,percent of total billed charges,48.48% of total billed charges,292.14,90,,233.712,percent of total billed charges,90% of total billed charges,48.48,292.14,
Calcium Alginate Dressing,,,270,RC,A6196,HCPCS,outpatient,,,43.34,26.00,,26,60,,20.8,percent of total billed charges,60% of total billed charges,20.8,48,,16.64,percent of total billed charges,48% of total billed charges,21.67,50,,17.336,percent of total billed charges,50% of total billed charges,21.67,50,,17.336,percent of total billed charges,50% of total billed charges,21.67,50,,17.336,percent of total billed charges,50% of total billed charges,21.67,50,,17.336,percent of total billed charges,50% of total billed charges,30.34,70,,24.272,percent of total billed charges,70% of total billed charges,21.01,48.48,,16.808,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,21.01,48.48,,16.808,percent of total billed charges,48.48% of total billed charges,30.34,70,,24.272,percent of total billed charges,70% of total billed charges,30.34,70,,24.272,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,21.01,48.48,,16.808,percent of total billed charges,48.48% of total billed charges,39.01,90,,31.208,percent of total billed charges,90% of total billed charges,21.01,90,
GAUZE SPONGES/PKG STERILE,,,270,RC,,,outpatient,,,15.13,9.08,,9.08,60,,7.264,percent of total billed charges,60% of total billed charges,7.26,48,,5.808,percent of total billed charges,48% of total billed charges,7.57,50,,6.056,percent of total billed charges,50% of total billed charges,7.57,50,,6.056,percent of total billed charges,50% of total billed charges,7.57,50,,6.056,percent of total billed charges,50% of total billed charges,7.57,50,,6.056,percent of total billed charges,50% of total billed charges,10.59,70,,8.472,percent of total billed charges,70% of total billed charges,7.34,48.48,,5.872,percent of total billed charges,48.48% of total billed charges,7.34,48.48,,5.872,percent of total billed charges,48.48% of total billed charges,7.34,48.48,,5.872,percent of total billed charges,48.48% of total billed charges,10.59,70,,8.472,percent of total billed charges,70% of total billed charges,10.59,70,,8.472,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,7.34,48.48,,5.872,percent of total billed charges,48.48% of total billed charges,13.62,90,,10.896,percent of total billed charges,90% of total billed charges,7.34,90,
HEEL PROTECTORS/PAIR,,,270,RC,,,outpatient,,,32.51,19.51,,19.51,60,,15.608,percent of total billed charges,60% of total billed charges,15.6,48,,12.48,percent of total billed charges,48% of total billed charges,16.26,50,,13.008,percent of total billed charges,50% of total billed charges,16.26,50,,13.008,percent of total billed charges,50% of total billed charges,16.26,50,,13.008,percent of total billed charges,50% of total billed charges,16.26,50,,13.008,percent of total billed charges,50% of total billed charges,22.76,70,,18.208,percent of total billed charges,70% of total billed charges,15.76,48.48,,12.608,percent of total billed charges,48.48% of total billed charges,15.76,48.48,,12.608,percent of total billed charges,48.48% of total billed charges,15.76,48.48,,12.608,percent of total billed charges,48.48% of total billed charges,22.76,70,,18.208,percent of total billed charges,70% of total billed charges,22.76,70,,18.208,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,15.76,48.48,,12.608,percent of total billed charges,48.48% of total billed charges,29.26,90,,23.408,percent of total billed charges,90% of total billed charges,15.76,90,
Silver Alginate Dressing,,,270,RC,A6199,HCPCS,outpatient,,,43.05,25.83,,25.83,60,,20.664,percent of total billed charges,60% of total billed charges,20.66,48,,16.528,percent of total billed charges,48% of total billed charges,21.53,50,,17.224,percent of total billed charges,50% of total billed charges,21.53,50,,17.224,percent of total billed charges,50% of total billed charges,21.53,50,,17.224,percent of total billed charges,50% of total billed charges,21.53,50,,17.224,percent of total billed charges,50% of total billed charges,30.14,70,,24.112,percent of total billed charges,70% of total billed charges,20.87,48.48,,16.696,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,20.87,48.48,,16.696,percent of total billed charges,48.48% of total billed charges,30.14,70,,24.112,percent of total billed charges,70% of total billed charges,30.14,70,,24.112,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,20.87,48.48,,16.696,percent of total billed charges,48.48% of total billed charges,38.75,90,,31,percent of total billed charges,90% of total billed charges,20.87,90,
Melgisorb Plus Dressing,,,270,RC,A6199,HCPCS,outpatient,,,45.65,27.39,,27.39,60,,21.912,percent of total billed charges,60% of total billed charges,21.91,48,,17.528,percent of total billed charges,48% of total billed charges,22.83,50,,18.264,percent of total billed charges,50% of total billed charges,22.83,50,,18.264,percent of total billed charges,50% of total billed charges,22.83,50,,18.264,percent of total billed charges,50% of total billed charges,22.83,50,,18.264,percent of total billed charges,50% of total billed charges,31.96,70,,25.568,percent of total billed charges,70% of total billed charges,22.13,48.48,,17.704,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,22.13,48.48,,17.704,percent of total billed charges,48.48% of total billed charges,31.96,70,,25.568,percent of total billed charges,70% of total billed charges,31.96,70,,25.568,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,22.13,48.48,,17.704,percent of total billed charges,48.48% of total billed charges,41.09,90,,32.872,percent of total billed charges,90% of total billed charges,22.13,90,
Mesalt Dressing 4x4,,,270,RC,A6222,HCPCS,outpatient,,,15.84,9.50,,9.5,60,,7.6,percent of total billed charges,60% of total billed charges,7.6,48,,6.08,percent of total billed charges,48% of total billed charges,7.92,50,,6.336,percent of total billed charges,50% of total billed charges,7.92,50,,6.336,percent of total billed charges,50% of total billed charges,7.92,50,,6.336,percent of total billed charges,50% of total billed charges,7.92,50,,6.336,percent of total billed charges,50% of total billed charges,11.09,70,,8.872,percent of total billed charges,70% of total billed charges,7.68,48.48,,6.144,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,7.68,48.48,,6.144,percent of total billed charges,48.48% of total billed charges,11.09,70,,8.872,percent of total billed charges,70% of total billed charges,11.09,70,,8.872,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,7.68,48.48,,6.144,percent of total billed charges,48.48% of total billed charges,14.26,90,,11.408,percent of total billed charges,90% of total billed charges,7.68,90,
Silicon Foam Dressing 4x4,,,270,RC,A6213,HCPCS,outpatient,,,39.05,23.43,,23.43,60,,18.744,percent of total billed charges,60% of total billed charges,18.74,48,,14.992,percent of total billed charges,48% of total billed charges,19.53,50,,15.624,percent of total billed charges,50% of total billed charges,19.53,50,,15.624,percent of total billed charges,50% of total billed charges,19.53,50,,15.624,percent of total billed charges,50% of total billed charges,19.53,50,,15.624,percent of total billed charges,50% of total billed charges,27.34,70,,21.872,percent of total billed charges,70% of total billed charges,18.93,48.48,,15.144,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,18.93,48.48,,15.144,percent of total billed charges,48.48% of total billed charges,27.34,70,,21.872,percent of total billed charges,70% of total billed charges,27.34,70,,21.872,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,18.93,48.48,,15.144,percent of total billed charges,48.48% of total billed charges,35.15,90,,28.12,percent of total billed charges,90% of total billed charges,18.93,90,
Silver Alginate Silvercel Dressing 2x2,,,270,RC,A6196,HCPCS,outpatient,,,27.17,16.30,,16.3,60,,13.04,percent of total billed charges,60% of total billed charges,13.04,48,,10.432,percent of total billed charges,48% of total billed charges,13.59,50,,10.872,percent of total billed charges,50% of total billed charges,13.59,50,,10.872,percent of total billed charges,50% of total billed charges,13.59,50,,10.872,percent of total billed charges,50% of total billed charges,13.59,50,,10.872,percent of total billed charges,50% of total billed charges,19.02,70,,15.216,percent of total billed charges,70% of total billed charges,13.17,48.48,,10.536,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,13.17,48.48,,10.536,percent of total billed charges,48.48% of total billed charges,19.02,70,,15.216,percent of total billed charges,70% of total billed charges,19.02,70,,15.216,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,13.17,48.48,,10.536,percent of total billed charges,48.48% of total billed charges,24.45,90,,19.56,percent of total billed charges,90% of total billed charges,13.17,90,
Tegaderm Dressing 6x8,,,270,RC,A6258,HCPCS,outpatient,,,22.44,13.46,,13.46,60,,10.768,percent of total billed charges,60% of total billed charges,10.77,48,,8.616,percent of total billed charges,48% of total billed charges,11.22,50,,8.976,percent of total billed charges,50% of total billed charges,11.22,50,,8.976,percent of total billed charges,50% of total billed charges,11.22,50,,8.976,percent of total billed charges,50% of total billed charges,11.22,50,,8.976,percent of total billed charges,50% of total billed charges,15.71,70,,12.568,percent of total billed charges,70% of total billed charges,10.88,48.48,,8.704,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,10.88,48.48,,8.704,percent of total billed charges,48.48% of total billed charges,15.71,70,,12.568,percent of total billed charges,70% of total billed charges,15.71,70,,12.568,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,10.88,48.48,,8.704,percent of total billed charges,48.48% of total billed charges,20.2,90,,16.16,percent of total billed charges,90% of total billed charges,10.88,90,
DUODERM DRESSING PKG.,,,270,RC,,,outpatient,,,24.2,14.52,,14.52,60,,11.616,percent of total billed charges,60% of total billed charges,11.62,48,,9.296,percent of total billed charges,48% of total billed charges,12.1,50,,9.68,percent of total billed charges,50% of total billed charges,12.1,50,,9.68,percent of total billed charges,50% of total billed charges,12.1,50,,9.68,percent of total billed charges,50% of total billed charges,12.1,50,,9.68,percent of total billed charges,50% of total billed charges,16.94,70,,13.552,percent of total billed charges,70% of total billed charges,11.73,48.48,,9.384,percent of total billed charges,48.48% of total billed charges,11.73,48.48,,9.384,percent of total billed charges,48.48% of total billed charges,11.73,48.48,,9.384,percent of total billed charges,48.48% of total billed charges,16.94,70,,13.552,percent of total billed charges,70% of total billed charges,16.94,70,,13.552,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,11.73,48.48,,9.384,percent of total billed charges,48.48% of total billed charges,21.78,90,,17.424,percent of total billed charges,90% of total billed charges,11.73,90,
Hibiclens 4 oz,,,270,RC,A6260,HCPCS,outpatient,,,35.64,21.38,,21.38,60,,17.104,percent of total billed charges,60% of total billed charges,17.11,48,,13.688,percent of total billed charges,48% of total billed charges,17.82,50,,14.256,percent of total billed charges,50% of total billed charges,17.82,50,,14.256,percent of total billed charges,50% of total billed charges,17.82,50,,14.256,percent of total billed charges,50% of total billed charges,17.82,50,,14.256,percent of total billed charges,50% of total billed charges,24.95,70,,19.96,percent of total billed charges,70% of total billed charges,17.28,48.48,,13.824,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,17.28,48.48,,13.824,percent of total billed charges,48.48% of total billed charges,24.95,70,,19.96,percent of total billed charges,70% of total billed charges,24.95,70,,19.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,17.28,48.48,,13.824,percent of total billed charges,48.48% of total billed charges,32.08,90,,25.664,percent of total billed charges,90% of total billed charges,17.28,90,
SCD SLEEVE MEDIUM,,,270,RC,A4600,HCPCS,outpatient,,,217.84,130.70,,130.7,60,,104.56,percent of total billed charges,60% of total billed charges,104.56,48,,83.648,percent of total billed charges,48% of total billed charges,108.92,50,,87.136,percent of total billed charges,50% of total billed charges,108.92,50,,87.136,percent of total billed charges,50% of total billed charges,108.92,50,,87.136,percent of total billed charges,50% of total billed charges,108.92,50,,87.136,percent of total billed charges,50% of total billed charges,152.49,70,,121.992,percent of total billed charges,70% of total billed charges,105.61,48.48,,84.488,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,105.61,48.48,,84.488,percent of total billed charges,48.48% of total billed charges,152.49,70,,121.992,percent of total billed charges,70% of total billed charges,152.49,70,,121.992,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,105.61,48.48,,84.488,percent of total billed charges,48.48% of total billed charges,196.06,90,,156.848,percent of total billed charges,90% of total billed charges,48.48,196.06,
SCD SLEEVE LARGE,,,270,RC,A4600,HCPCS,outpatient,,,259.48,155.69,,155.69,60,,124.552,percent of total billed charges,60% of total billed charges,124.55,48,,99.64,percent of total billed charges,48% of total billed charges,129.74,50,,103.792,percent of total billed charges,50% of total billed charges,129.74,50,,103.792,percent of total billed charges,50% of total billed charges,129.74,50,,103.792,percent of total billed charges,50% of total billed charges,129.74,50,,103.792,percent of total billed charges,50% of total billed charges,181.64,70,,145.312,percent of total billed charges,70% of total billed charges,125.8,48.48,,100.64,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,125.8,48.48,,100.64,percent of total billed charges,48.48% of total billed charges,181.64,70,,145.312,percent of total billed charges,70% of total billed charges,181.64,70,,145.312,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,125.8,48.48,,100.64,percent of total billed charges,48.48% of total billed charges,233.53,90,,186.824,percent of total billed charges,90% of total billed charges,48.48,233.53,
SCD SLEEVE X-LARGE,,,270,RC,A4600,HCPCS,outpatient,,,298.32,178.99,,178.99,60,,143.192,percent of total billed charges,60% of total billed charges,143.19,48,,114.552,percent of total billed charges,48% of total billed charges,149.16,50,,119.328,percent of total billed charges,50% of total billed charges,149.16,50,,119.328,percent of total billed charges,50% of total billed charges,149.16,50,,119.328,percent of total billed charges,50% of total billed charges,149.16,50,,119.328,percent of total billed charges,50% of total billed charges,208.82,70,,167.056,percent of total billed charges,70% of total billed charges,144.63,48.48,,115.704,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,144.63,48.48,,115.704,percent of total billed charges,48.48% of total billed charges,208.82,70,,167.056,percent of total billed charges,70% of total billed charges,208.82,70,,167.056,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,144.63,48.48,,115.704,percent of total billed charges,48.48% of total billed charges,268.49,90,,214.792,percent of total billed charges,90% of total billed charges,48.48,268.49,
"ELBOW IMMOBILIZER, PEDIATRIC",,,274,RC,L3760,HCPCS,outpatient,,,54.71,32.83,,32.83,60,,26.264,percent of total billed charges,60% of total billed charges,26.26,48,,21.008,percent of total billed charges,48% of total billed charges,27.36,50,,21.888,percent of total billed charges,50% of total billed charges,27.36,50,,21.888,percent of total billed charges,50% of total billed charges,27.36,50,,21.888,percent of total billed charges,50% of total billed charges,27.36,50,,21.888,percent of total billed charges,50% of total billed charges,38.3,70,,30.64,percent of total billed charges,70% of total billed charges,26.52,48.48,,21.216,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,26.52,48.48,,21.216,percent of total billed charges,48.48% of total billed charges,38.3,70,,30.64,percent of total billed charges,70% of total billed charges,38.3,70,,30.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,26.52,48.48,,21.216,percent of total billed charges,48.48% of total billed charges,49.24,90,,39.392,percent of total billed charges,90% of total billed charges,26.52,90,
"SPLINT, WRIST, VELCRO",36039193,CDM,274,RC,L3908,HCPCS,outpatient,,,64.58,38.75,,38.75,60,,31,percent of total billed charges,60% of total billed charges,31,48,,24.8,percent of total billed charges,48% of total billed charges,32.29,50,,25.832,percent of total billed charges,50% of total billed charges,32.29,50,,25.832,percent of total billed charges,50% of total billed charges,32.29,50,,25.832,percent of total billed charges,50% of total billed charges,32.29,50,,25.832,percent of total billed charges,50% of total billed charges,45.21,70,,36.168,percent of total billed charges,70% of total billed charges,31.31,48.48,,25.048,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,31.31,48.48,,25.048,percent of total billed charges,48.48% of total billed charges,45.21,70,,36.168,percent of total billed charges,70% of total billed charges,45.21,70,,36.168,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,31.31,48.48,,25.048,percent of total billed charges,48.48% of total billed charges,58.12,90,,46.496,percent of total billed charges,90% of total billed charges,31.31,90,
NASAL TRAY,,,270,RC,,,outpatient,,,121,72.60,,72.6,60,,58.08,percent of total billed charges,60% of total billed charges,58.08,48,,46.464,percent of total billed charges,48% of total billed charges,60.5,50,,48.4,percent of total billed charges,50% of total billed charges,60.5,50,,48.4,percent of total billed charges,50% of total billed charges,60.5,50,,48.4,percent of total billed charges,50% of total billed charges,60.5,50,,48.4,percent of total billed charges,50% of total billed charges,84.7,70,,67.76,percent of total billed charges,70% of total billed charges,58.66,48.48,,46.928,percent of total billed charges,48.48% of total billed charges,58.66,48.48,,46.928,percent of total billed charges,48.48% of total billed charges,58.66,48.48,,46.928,percent of total billed charges,48.48% of total billed charges,84.7,70,,67.76,percent of total billed charges,70% of total billed charges,84.7,70,,67.76,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,58.66,48.48,,46.928,percent of total billed charges,48.48% of total billed charges,108.9,90,,87.12,percent of total billed charges,90% of total billed charges,48.48,108.9,
Duoderm CGF,,,270,RC,A6234,HCPCS,outpatient,,,53.79,32.27,,32.27,60,,25.816,percent of total billed charges,60% of total billed charges,25.82,48,,20.656,percent of total billed charges,48% of total billed charges,26.9,50,,21.52,percent of total billed charges,50% of total billed charges,26.9,50,,21.52,percent of total billed charges,50% of total billed charges,26.9,50,,21.52,percent of total billed charges,50% of total billed charges,26.9,50,,21.52,percent of total billed charges,50% of total billed charges,37.65,70,,30.12,percent of total billed charges,70% of total billed charges,26.08,48.48,,20.864,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,26.08,48.48,,20.864,percent of total billed charges,48.48% of total billed charges,37.65,70,,30.12,percent of total billed charges,70% of total billed charges,37.65,70,,30.12,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,26.08,48.48,,20.864,percent of total billed charges,48.48% of total billed charges,48.41,90,,38.728,percent of total billed charges,90% of total billed charges,26.08,90,
Mesalt Dressing 3x11,,,270,RC,A6266,HCPCS,outpatient,,,32.78,19.67,,19.67,60,,15.736,percent of total billed charges,60% of total billed charges,15.73,48,,12.584,percent of total billed charges,48% of total billed charges,16.39,50,,13.112,percent of total billed charges,50% of total billed charges,16.39,50,,13.112,percent of total billed charges,50% of total billed charges,16.39,50,,13.112,percent of total billed charges,50% of total billed charges,16.39,50,,13.112,percent of total billed charges,50% of total billed charges,22.95,70,,18.36,percent of total billed charges,70% of total billed charges,15.89,48.48,,12.712,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,15.89,48.48,,12.712,percent of total billed charges,48.48% of total billed charges,22.95,70,,18.36,percent of total billed charges,70% of total billed charges,22.95,70,,18.36,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,15.89,48.48,,12.712,percent of total billed charges,48.48% of total billed charges,29.5,90,,23.6,percent of total billed charges,90% of total billed charges,15.89,90,
QUICK CATH.,,,270,RC,,,outpatient,,,42.35,25.41,,25.41,60,,20.328,percent of total billed charges,60% of total billed charges,20.33,48,,16.264,percent of total billed charges,48% of total billed charges,21.18,50,,16.944,percent of total billed charges,50% of total billed charges,21.18,50,,16.944,percent of total billed charges,50% of total billed charges,21.18,50,,16.944,percent of total billed charges,50% of total billed charges,21.18,50,,16.944,percent of total billed charges,50% of total billed charges,29.65,70,,23.72,percent of total billed charges,70% of total billed charges,20.53,48.48,,16.424,percent of total billed charges,48.48% of total billed charges,20.53,48.48,,16.424,percent of total billed charges,48.48% of total billed charges,20.53,48.48,,16.424,percent of total billed charges,48.48% of total billed charges,29.65,70,,23.72,percent of total billed charges,70% of total billed charges,29.65,70,,23.72,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,20.53,48.48,,16.424,percent of total billed charges,48.48% of total billed charges,38.12,90,,30.496,percent of total billed charges,90% of total billed charges,20.53,90,
WRIST SPLINT,,,274,RC,,,outpatient,,,55,33.00,,33,60,,26.4,percent of total billed charges,60% of total billed charges,26.4,48,,21.12,percent of total billed charges,48% of total billed charges,27.5,50,,22,percent of total billed charges,50% of total billed charges,27.5,50,,22,percent of total billed charges,50% of total billed charges,27.5,50,,22,percent of total billed charges,50% of total billed charges,27.5,50,,22,percent of total billed charges,50% of total billed charges,38.5,70,,30.8,percent of total billed charges,70% of total billed charges,26.66,48.48,,21.328,percent of total billed charges,48.48% of total billed charges,26.66,48.48,,21.328,percent of total billed charges,48.48% of total billed charges,26.66,48.48,,21.328,percent of total billed charges,48.48% of total billed charges,38.5,70,,30.8,percent of total billed charges,70% of total billed charges,38.5,70,,30.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,26.66,48.48,,21.328,percent of total billed charges,48.48% of total billed charges,49.5,90,,39.6,percent of total billed charges,90% of total billed charges,26.66,90,
SPLINT/FINGER,43601542,CDM,270,RC,Q4049,HCPCS,outpatient,,,21.78,13.07,,13.07,60,,10.456,percent of total billed charges,60% of total billed charges,10.45,48,,8.36,percent of total billed charges,48% of total billed charges,10.89,50,,8.712,percent of total billed charges,50% of total billed charges,10.89,50,,8.712,percent of total billed charges,50% of total billed charges,10.89,50,,8.712,percent of total billed charges,50% of total billed charges,10.89,50,,8.712,percent of total billed charges,50% of total billed charges,15.25,70,,12.2,percent of total billed charges,70% of total billed charges,10.56,48.48,,8.448,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,10.56,48.48,,8.448,percent of total billed charges,48.48% of total billed charges,15.25,70,,12.2,percent of total billed charges,70% of total billed charges,15.25,70,,12.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,10.56,48.48,,8.448,percent of total billed charges,48.48% of total billed charges,19.6,90,,15.68,percent of total billed charges,90% of total billed charges,10.56,90,
SUTURES/PACKAGE,,,270,RC,,,outpatient,,,10.89,6.53,,6.53,60,,5.224,percent of total billed charges,60% of total billed charges,5.23,48,,4.184,percent of total billed charges,48% of total billed charges,5.45,50,,4.36,percent of total billed charges,50% of total billed charges,5.45,50,,4.36,percent of total billed charges,50% of total billed charges,5.45,50,,4.36,percent of total billed charges,50% of total billed charges,5.45,50,,4.36,percent of total billed charges,50% of total billed charges,7.62,70,,6.096,percent of total billed charges,70% of total billed charges,5.28,48.48,,4.224,percent of total billed charges,48.48% of total billed charges,5.28,48.48,,4.224,percent of total billed charges,48.48% of total billed charges,5.28,48.48,,4.224,percent of total billed charges,48.48% of total billed charges,7.62,70,,6.096,percent of total billed charges,70% of total billed charges,7.62,70,,6.096,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,5.28,48.48,,4.224,percent of total billed charges,48.48% of total billed charges,9.8,90,,7.84,percent of total billed charges,90% of total billed charges,5.28,90,
SUTURE TRAY,,,270,RC,,,outpatient,,,48.4,29.04,,29.04,60,,23.232,percent of total billed charges,60% of total billed charges,23.23,48,,18.584,percent of total billed charges,48% of total billed charges,24.2,50,,19.36,percent of total billed charges,50% of total billed charges,24.2,50,,19.36,percent of total billed charges,50% of total billed charges,24.2,50,,19.36,percent of total billed charges,50% of total billed charges,24.2,50,,19.36,percent of total billed charges,50% of total billed charges,33.88,70,,27.104,percent of total billed charges,70% of total billed charges,23.46,48.48,,18.768,percent of total billed charges,48.48% of total billed charges,23.46,48.48,,18.768,percent of total billed charges,48.48% of total billed charges,23.46,48.48,,18.768,percent of total billed charges,48.48% of total billed charges,33.88,70,,27.104,percent of total billed charges,70% of total billed charges,33.88,70,,27.104,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,23.46,48.48,,18.768,percent of total billed charges,48.48% of total billed charges,43.56,90,,34.848,percent of total billed charges,90% of total billed charges,23.46,90,
SUCTION CONTROL CATHETER,,,270,RC,,,outpatient,,,24.2,14.52,,14.52,60,,11.616,percent of total billed charges,60% of total billed charges,11.62,48,,9.296,percent of total billed charges,48% of total billed charges,12.1,50,,9.68,percent of total billed charges,50% of total billed charges,12.1,50,,9.68,percent of total billed charges,50% of total billed charges,12.1,50,,9.68,percent of total billed charges,50% of total billed charges,12.1,50,,9.68,percent of total billed charges,50% of total billed charges,16.94,70,,13.552,percent of total billed charges,70% of total billed charges,11.73,48.48,,9.384,percent of total billed charges,48.48% of total billed charges,11.73,48.48,,9.384,percent of total billed charges,48.48% of total billed charges,11.73,48.48,,9.384,percent of total billed charges,48.48% of total billed charges,16.94,70,,13.552,percent of total billed charges,70% of total billed charges,16.94,70,,13.552,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,11.73,48.48,,9.384,percent of total billed charges,48.48% of total billed charges,21.78,90,,17.424,percent of total billed charges,90% of total billed charges,11.73,90,
TRAY-FOLEY CATHETER,,,270,RC,,,outpatient,,,93.5,56.10,,56.1,60,,44.88,percent of total billed charges,60% of total billed charges,44.88,48,,35.904,percent of total billed charges,48% of total billed charges,46.75,50,,37.4,percent of total billed charges,50% of total billed charges,46.75,50,,37.4,percent of total billed charges,50% of total billed charges,46.75,50,,37.4,percent of total billed charges,50% of total billed charges,46.75,50,,37.4,percent of total billed charges,50% of total billed charges,65.45,70,,52.36,percent of total billed charges,70% of total billed charges,45.33,48.48,,36.264,percent of total billed charges,48.48% of total billed charges,45.33,48.48,,36.264,percent of total billed charges,48.48% of total billed charges,45.33,48.48,,36.264,percent of total billed charges,48.48% of total billed charges,65.45,70,,52.36,percent of total billed charges,70% of total billed charges,65.45,70,,52.36,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,45.33,48.48,,36.264,percent of total billed charges,48.48% of total billed charges,84.15,90,,67.32,percent of total billed charges,90% of total billed charges,45.33,90,
"TRAY, IRRIG, PISTON SYRINGE",,,270,RC,A4320,HCPCS,outpatient,,,19.36,11.62,,11.62,60,,9.296,percent of total billed charges,60% of total billed charges,9.29,48,,7.432,percent of total billed charges,48% of total billed charges,9.68,50,,7.744,percent of total billed charges,50% of total billed charges,9.68,50,,7.744,percent of total billed charges,50% of total billed charges,9.68,50,,7.744,percent of total billed charges,50% of total billed charges,9.68,50,,7.744,percent of total billed charges,50% of total billed charges,13.55,70,,10.84,percent of total billed charges,70% of total billed charges,9.39,48.48,,7.512,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.39,48.48,,7.512,percent of total billed charges,48.48% of total billed charges,13.55,70,,10.84,percent of total billed charges,70% of total billed charges,13.55,70,,10.84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.39,48.48,,7.512,percent of total billed charges,48.48% of total billed charges,17.42,90,,13.936,percent of total billed charges,90% of total billed charges,9.39,90,
IV TRAY/START KIT,,,270,RC,,,outpatient,,,36.3,21.78,,21.78,60,,17.424,percent of total billed charges,60% of total billed charges,17.42,48,,13.936,percent of total billed charges,48% of total billed charges,18.15,50,,14.52,percent of total billed charges,50% of total billed charges,18.15,50,,14.52,percent of total billed charges,50% of total billed charges,18.15,50,,14.52,percent of total billed charges,50% of total billed charges,18.15,50,,14.52,percent of total billed charges,50% of total billed charges,25.41,70,,20.328,percent of total billed charges,70% of total billed charges,17.6,48.48,,14.08,percent of total billed charges,48.48% of total billed charges,17.6,48.48,,14.08,percent of total billed charges,48.48% of total billed charges,17.6,48.48,,14.08,percent of total billed charges,48.48% of total billed charges,25.41,70,,20.328,percent of total billed charges,70% of total billed charges,25.41,70,,20.328,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,17.6,48.48,,14.08,percent of total billed charges,48.48% of total billed charges,32.67,90,,26.136,percent of total billed charges,90% of total billed charges,17.6,90,
TRAY-SPINAL PUNCTURE,,,270,RC,,,outpatient,,,66.55,39.93,,39.93,60,,31.944,percent of total billed charges,60% of total billed charges,31.94,48,,25.552,percent of total billed charges,48% of total billed charges,33.28,50,,26.624,percent of total billed charges,50% of total billed charges,33.28,50,,26.624,percent of total billed charges,50% of total billed charges,33.28,50,,26.624,percent of total billed charges,50% of total billed charges,33.28,50,,26.624,percent of total billed charges,50% of total billed charges,46.59,70,,37.272,percent of total billed charges,70% of total billed charges,32.26,48.48,,25.808,percent of total billed charges,48.48% of total billed charges,32.26,48.48,,25.808,percent of total billed charges,48.48% of total billed charges,32.26,48.48,,25.808,percent of total billed charges,48.48% of total billed charges,46.59,70,,37.272,percent of total billed charges,70% of total billed charges,46.59,70,,37.272,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,32.26,48.48,,25.808,percent of total billed charges,48.48% of total billed charges,59.9,90,,47.92,percent of total billed charges,90% of total billed charges,32.26,90,
"TRAY, SUCTION",,,270,RC,,,outpatient,,,55,33.00,,33,60,,26.4,percent of total billed charges,60% of total billed charges,26.4,48,,21.12,percent of total billed charges,48% of total billed charges,27.5,50,,22,percent of total billed charges,50% of total billed charges,27.5,50,,22,percent of total billed charges,50% of total billed charges,27.5,50,,22,percent of total billed charges,50% of total billed charges,27.5,50,,22,percent of total billed charges,50% of total billed charges,38.5,70,,30.8,percent of total billed charges,70% of total billed charges,26.66,48.48,,21.328,percent of total billed charges,48.48% of total billed charges,26.66,48.48,,21.328,percent of total billed charges,48.48% of total billed charges,26.66,48.48,,21.328,percent of total billed charges,48.48% of total billed charges,38.5,70,,30.8,percent of total billed charges,70% of total billed charges,38.5,70,,30.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,26.66,48.48,,21.328,percent of total billed charges,48.48% of total billed charges,49.5,90,,39.6,percent of total billed charges,90% of total billed charges,26.66,90,
TRAY-NON CORING NEEDLE,,,271,RC,,,outpatient,,,181.5,108.90,,108.9,60,,87.12,percent of total billed charges,60% of total billed charges,87.12,48,,69.696,percent of total billed charges,48% of total billed charges,90.75,50,,72.6,percent of total billed charges,50% of total billed charges,90.75,50,,72.6,percent of total billed charges,50% of total billed charges,90.75,50,,72.6,percent of total billed charges,50% of total billed charges,90.75,50,,72.6,percent of total billed charges,50% of total billed charges,127.05,70,,101.64,percent of total billed charges,70% of total billed charges,87.99,48.48,,70.392,percent of total billed charges,48.48% of total billed charges,87.99,48.48,,70.392,percent of total billed charges,48.48% of total billed charges,87.99,48.48,,70.392,percent of total billed charges,48.48% of total billed charges,127.05,70,,101.64,percent of total billed charges,70% of total billed charges,127.05,70,,101.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,87.99,48.48,,70.392,percent of total billed charges,48.48% of total billed charges,163.35,90,,130.68,percent of total billed charges,90% of total billed charges,48.48,163.35,
TRI-PADS/PKG OF 10.,,,270,RC,,,outpatient,,,16.09,9.65,,9.65,60,,7.72,percent of total billed charges,60% of total billed charges,7.72,48,,6.176,percent of total billed charges,48% of total billed charges,8.05,50,,6.44,percent of total billed charges,50% of total billed charges,8.05,50,,6.44,percent of total billed charges,50% of total billed charges,8.05,50,,6.44,percent of total billed charges,50% of total billed charges,8.05,50,,6.44,percent of total billed charges,50% of total billed charges,11.26,70,,9.008,percent of total billed charges,70% of total billed charges,7.8,48.48,,6.24,percent of total billed charges,48.48% of total billed charges,7.8,48.48,,6.24,percent of total billed charges,48.48% of total billed charges,7.8,48.48,,6.24,percent of total billed charges,48.48% of total billed charges,11.26,70,,9.008,percent of total billed charges,70% of total billed charges,11.26,70,,9.008,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,7.8,48.48,,6.24,percent of total billed charges,48.48% of total billed charges,14.48,90,,11.584,percent of total billed charges,90% of total billed charges,7.8,90,
TRAY SUTURE REMOVAL,,,270,RC,,,outpatient,,,19.36,11.62,,11.62,60,,9.296,percent of total billed charges,60% of total billed charges,9.29,48,,7.432,percent of total billed charges,48% of total billed charges,9.68,50,,7.744,percent of total billed charges,50% of total billed charges,9.68,50,,7.744,percent of total billed charges,50% of total billed charges,9.68,50,,7.744,percent of total billed charges,50% of total billed charges,9.68,50,,7.744,percent of total billed charges,50% of total billed charges,13.55,70,,10.84,percent of total billed charges,70% of total billed charges,9.39,48.48,,7.512,percent of total billed charges,48.48% of total billed charges,9.39,48.48,,7.512,percent of total billed charges,48.48% of total billed charges,9.39,48.48,,7.512,percent of total billed charges,48.48% of total billed charges,13.55,70,,10.84,percent of total billed charges,70% of total billed charges,13.55,70,,10.84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.39,48.48,,7.512,percent of total billed charges,48.48% of total billed charges,17.42,90,,13.936,percent of total billed charges,90% of total billed charges,9.39,90,
TRAY-STRAIGHT CATH,,,270,RC,,,outpatient,,,42.35,25.41,,25.41,60,,20.328,percent of total billed charges,60% of total billed charges,20.33,48,,16.264,percent of total billed charges,48% of total billed charges,21.18,50,,16.944,percent of total billed charges,50% of total billed charges,21.18,50,,16.944,percent of total billed charges,50% of total billed charges,21.18,50,,16.944,percent of total billed charges,50% of total billed charges,21.18,50,,16.944,percent of total billed charges,50% of total billed charges,29.65,70,,23.72,percent of total billed charges,70% of total billed charges,20.53,48.48,,16.424,percent of total billed charges,48.48% of total billed charges,20.53,48.48,,16.424,percent of total billed charges,48.48% of total billed charges,20.53,48.48,,16.424,percent of total billed charges,48.48% of total billed charges,29.65,70,,23.72,percent of total billed charges,70% of total billed charges,29.65,70,,23.72,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,20.53,48.48,,16.424,percent of total billed charges,48.48% of total billed charges,38.12,90,,30.496,percent of total billed charges,90% of total billed charges,20.53,90,
PEAK-FLOW METER(SPIR-O-FL,,,270,RC,,,outpatient,,,36.3,21.78,,21.78,60,,17.424,percent of total billed charges,60% of total billed charges,17.42,48,,13.936,percent of total billed charges,48% of total billed charges,18.15,50,,14.52,percent of total billed charges,50% of total billed charges,18.15,50,,14.52,percent of total billed charges,50% of total billed charges,18.15,50,,14.52,percent of total billed charges,50% of total billed charges,18.15,50,,14.52,percent of total billed charges,50% of total billed charges,25.41,70,,20.328,percent of total billed charges,70% of total billed charges,17.6,48.48,,14.08,percent of total billed charges,48.48% of total billed charges,17.6,48.48,,14.08,percent of total billed charges,48.48% of total billed charges,17.6,48.48,,14.08,percent of total billed charges,48.48% of total billed charges,25.41,70,,20.328,percent of total billed charges,70% of total billed charges,25.41,70,,20.328,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,17.6,48.48,,14.08,percent of total billed charges,48.48% of total billed charges,32.67,90,,26.136,percent of total billed charges,90% of total billed charges,17.6,90,
CENTRAL LINE KIT,,,258,RC,,,outpatient,,,55,33.00,,33,60,,26.4,percent of total billed charges,60% of total billed charges,26.4,48,,21.12,percent of total billed charges,48% of total billed charges,27.5,50,,22,percent of total billed charges,50% of total billed charges,27.5,50,,22,percent of total billed charges,50% of total billed charges,27.5,50,,22,percent of total billed charges,50% of total billed charges,27.5,50,,22,percent of total billed charges,50% of total billed charges,38.5,70,,30.8,percent of total billed charges,70% of total billed charges,26.66,48.48,,21.328,percent of total billed charges,48.48% of total billed charges,26.66,48.48,,21.328,percent of total billed charges,48.48% of total billed charges,26.66,48.48,,21.328,percent of total billed charges,48.48% of total billed charges,38.5,70,,30.8,percent of total billed charges,70% of total billed charges,38.5,70,,30.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,26.66,48.48,,21.328,percent of total billed charges,48.48% of total billed charges,49.5,90,,39.6,percent of total billed charges,90% of total billed charges,26.66,90,
"IV, SECONDARY SET",,,270,RC,,,outpatient,,,21.78,13.07,,13.07,60,,10.456,percent of total billed charges,60% of total billed charges,10.45,48,,8.36,percent of total billed charges,48% of total billed charges,10.89,50,,8.712,percent of total billed charges,50% of total billed charges,10.89,50,,8.712,percent of total billed charges,50% of total billed charges,10.89,50,,8.712,percent of total billed charges,50% of total billed charges,10.89,50,,8.712,percent of total billed charges,50% of total billed charges,15.25,70,,12.2,percent of total billed charges,70% of total billed charges,10.56,48.48,,8.448,percent of total billed charges,48.48% of total billed charges,10.56,48.48,,8.448,percent of total billed charges,48.48% of total billed charges,10.56,48.48,,8.448,percent of total billed charges,48.48% of total billed charges,15.25,70,,12.2,percent of total billed charges,70% of total billed charges,15.25,70,,12.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,10.56,48.48,,8.448,percent of total billed charges,48.48% of total billed charges,19.6,90,,15.68,percent of total billed charges,90% of total billed charges,10.56,90,
HEPARIN FLUSH TRAY,,,270,RC,,,outpatient,,,27.5,16.50,,16.5,60,,13.2,percent of total billed charges,60% of total billed charges,13.2,48,,10.56,percent of total billed charges,48% of total billed charges,13.75,50,,11,percent of total billed charges,50% of total billed charges,13.75,50,,11,percent of total billed charges,50% of total billed charges,13.75,50,,11,percent of total billed charges,50% of total billed charges,13.75,50,,11,percent of total billed charges,50% of total billed charges,19.25,70,,15.4,percent of total billed charges,70% of total billed charges,13.33,48.48,,10.664,percent of total billed charges,48.48% of total billed charges,13.33,48.48,,10.664,percent of total billed charges,48.48% of total billed charges,13.33,48.48,,10.664,percent of total billed charges,48.48% of total billed charges,19.25,70,,15.4,percent of total billed charges,70% of total billed charges,19.25,70,,15.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,13.33,48.48,,10.664,percent of total billed charges,48.48% of total billed charges,24.75,90,,19.8,percent of total billed charges,90% of total billed charges,13.33,90,
EX.TRACHAR FR.WATER SEAL,,,270,RC,,,outpatient,,,48.4,29.04,,29.04,60,,23.232,percent of total billed charges,60% of total billed charges,23.23,48,,18.584,percent of total billed charges,48% of total billed charges,24.2,50,,19.36,percent of total billed charges,50% of total billed charges,24.2,50,,19.36,percent of total billed charges,50% of total billed charges,24.2,50,,19.36,percent of total billed charges,50% of total billed charges,24.2,50,,19.36,percent of total billed charges,50% of total billed charges,33.88,70,,27.104,percent of total billed charges,70% of total billed charges,23.46,48.48,,18.768,percent of total billed charges,48.48% of total billed charges,23.46,48.48,,18.768,percent of total billed charges,48.48% of total billed charges,23.46,48.48,,18.768,percent of total billed charges,48.48% of total billed charges,33.88,70,,27.104,percent of total billed charges,70% of total billed charges,33.88,70,,27.104,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,23.46,48.48,,18.768,percent of total billed charges,48.48% of total billed charges,43.56,90,,34.848,percent of total billed charges,90% of total billed charges,23.46,90,
DRESSING SUPPLIES,,,270,RC,,,outpatient,,,55,33.00,,33,60,,26.4,percent of total billed charges,60% of total billed charges,26.4,48,,21.12,percent of total billed charges,48% of total billed charges,27.5,50,,22,percent of total billed charges,50% of total billed charges,27.5,50,,22,percent of total billed charges,50% of total billed charges,27.5,50,,22,percent of total billed charges,50% of total billed charges,27.5,50,,22,percent of total billed charges,50% of total billed charges,38.5,70,,30.8,percent of total billed charges,70% of total billed charges,26.66,48.48,,21.328,percent of total billed charges,48.48% of total billed charges,26.66,48.48,,21.328,percent of total billed charges,48.48% of total billed charges,26.66,48.48,,21.328,percent of total billed charges,48.48% of total billed charges,38.5,70,,30.8,percent of total billed charges,70% of total billed charges,38.5,70,,30.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,26.66,48.48,,21.328,percent of total billed charges,48.48% of total billed charges,49.5,90,,39.6,percent of total billed charges,90% of total billed charges,26.66,90,
"SUPPLIES, REPACKING, DRESSING",,,270,RC,,,outpatient,,,55,33.00,,33,60,,26.4,percent of total billed charges,60% of total billed charges,26.4,48,,21.12,percent of total billed charges,48% of total billed charges,27.5,50,,22,percent of total billed charges,50% of total billed charges,27.5,50,,22,percent of total billed charges,50% of total billed charges,27.5,50,,22,percent of total billed charges,50% of total billed charges,27.5,50,,22,percent of total billed charges,50% of total billed charges,38.5,70,,30.8,percent of total billed charges,70% of total billed charges,26.66,48.48,,21.328,percent of total billed charges,48.48% of total billed charges,26.66,48.48,,21.328,percent of total billed charges,48.48% of total billed charges,26.66,48.48,,21.328,percent of total billed charges,48.48% of total billed charges,38.5,70,,30.8,percent of total billed charges,70% of total billed charges,38.5,70,,30.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,26.66,48.48,,21.328,percent of total billed charges,48.48% of total billed charges,49.5,90,,39.6,percent of total billed charges,90% of total billed charges,26.66,90,
ORAL SUCTION,,,270,RC,,,outpatient,,,12.1,7.26,,7.26,60,,5.808,percent of total billed charges,60% of total billed charges,5.81,48,,4.648,percent of total billed charges,48% of total billed charges,6.05,50,,4.84,percent of total billed charges,50% of total billed charges,6.05,50,,4.84,percent of total billed charges,50% of total billed charges,6.05,50,,4.84,percent of total billed charges,50% of total billed charges,6.05,50,,4.84,percent of total billed charges,50% of total billed charges,8.47,70,,6.776,percent of total billed charges,70% of total billed charges,5.87,48.48,,4.696,percent of total billed charges,48.48% of total billed charges,5.87,48.48,,4.696,percent of total billed charges,48.48% of total billed charges,5.87,48.48,,4.696,percent of total billed charges,48.48% of total billed charges,8.47,70,,6.776,percent of total billed charges,70% of total billed charges,8.47,70,,6.776,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,5.87,48.48,,4.696,percent of total billed charges,48.48% of total billed charges,10.89,90,,8.712,percent of total billed charges,90% of total billed charges,5.87,90,
NASOPHAYNGEAL SUCTION,,,270,RC,,,outpatient,,,12.1,7.26,,7.26,60,,5.808,percent of total billed charges,60% of total billed charges,5.81,48,,4.648,percent of total billed charges,48% of total billed charges,6.05,50,,4.84,percent of total billed charges,50% of total billed charges,6.05,50,,4.84,percent of total billed charges,50% of total billed charges,6.05,50,,4.84,percent of total billed charges,50% of total billed charges,6.05,50,,4.84,percent of total billed charges,50% of total billed charges,8.47,70,,6.776,percent of total billed charges,70% of total billed charges,5.87,48.48,,4.696,percent of total billed charges,48.48% of total billed charges,5.87,48.48,,4.696,percent of total billed charges,48.48% of total billed charges,5.87,48.48,,4.696,percent of total billed charges,48.48% of total billed charges,8.47,70,,6.776,percent of total billed charges,70% of total billed charges,8.47,70,,6.776,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,5.87,48.48,,4.696,percent of total billed charges,48.48% of total billed charges,10.89,90,,8.712,percent of total billed charges,90% of total billed charges,5.87,90,
NASAL TRUMPET,,,272,RC,,,outpatient,,,30.25,18.15,,18.15,60,,14.52,percent of total billed charges,60% of total billed charges,14.52,48,,11.616,percent of total billed charges,48% of total billed charges,15.13,50,,12.104,percent of total billed charges,50% of total billed charges,15.13,50,,12.104,percent of total billed charges,50% of total billed charges,15.13,50,,12.104,percent of total billed charges,50% of total billed charges,15.13,50,,12.104,percent of total billed charges,50% of total billed charges,21.18,70,,16.944,percent of total billed charges,70% of total billed charges,14.67,48.48,,11.736,percent of total billed charges,48.48% of total billed charges,14.67,48.48,,11.736,percent of total billed charges,48.48% of total billed charges,14.67,48.48,,11.736,percent of total billed charges,48.48% of total billed charges,21.18,70,,16.944,percent of total billed charges,70% of total billed charges,21.18,70,,16.944,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,14.67,48.48,,11.736,percent of total billed charges,48.48% of total billed charges,27.23,90,,21.784,percent of total billed charges,90% of total billed charges,14.67,90,
TED HOSE,,,270,RC,,,outpatient,,,48.4,29.04,,29.04,60,,23.232,percent of total billed charges,60% of total billed charges,23.23,48,,18.584,percent of total billed charges,48% of total billed charges,24.2,50,,19.36,percent of total billed charges,50% of total billed charges,24.2,50,,19.36,percent of total billed charges,50% of total billed charges,24.2,50,,19.36,percent of total billed charges,50% of total billed charges,24.2,50,,19.36,percent of total billed charges,50% of total billed charges,33.88,70,,27.104,percent of total billed charges,70% of total billed charges,23.46,48.48,,18.768,percent of total billed charges,48.48% of total billed charges,23.46,48.48,,18.768,percent of total billed charges,48.48% of total billed charges,23.46,48.48,,18.768,percent of total billed charges,48.48% of total billed charges,33.88,70,,27.104,percent of total billed charges,70% of total billed charges,33.88,70,,27.104,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,23.46,48.48,,18.768,percent of total billed charges,48.48% of total billed charges,43.56,90,,34.848,percent of total billed charges,90% of total billed charges,23.46,90,
DERMABOND GLUE,36039135,CDM,270,RC,G0168,HCPCS,outpatient,,,61.6,36.96,,36.96,60,,29.568,percent of total billed charges,60% of total billed charges,29.57,48,,23.656,percent of total billed charges,48% of total billed charges,30.8,50,,24.64,percent of total billed charges,50% of total billed charges,30.8,50,,24.64,percent of total billed charges,50% of total billed charges,30.8,50,,24.64,percent of total billed charges,50% of total billed charges,30.8,50,,24.64,percent of total billed charges,50% of total billed charges,43.12,70,,34.496,percent of total billed charges,70% of total billed charges,29.86,48.48,,23.888,percent of total billed charges,48.48% of total billed charges,17,116.15,,,fee schedule,116.51% of cms physician fee schedule,29.86,48.48,,23.888,percent of total billed charges,48.48% of total billed charges,43.12,70,,34.496,percent of total billed charges,70% of total billed charges,43.12,70,,34.496,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,29.86,48.48,,23.888,percent of total billed charges,48.48% of total billed charges,55.44,90,,44.352,percent of total billed charges,90% of total billed charges,29.86,90,
OB PACK W/SUPPLIES,,,270,RC,,,outpatient,,,181.5,108.90,,108.9,60,,87.12,percent of total billed charges,60% of total billed charges,87.12,48,,69.696,percent of total billed charges,48% of total billed charges,90.75,50,,72.6,percent of total billed charges,50% of total billed charges,90.75,50,,72.6,percent of total billed charges,50% of total billed charges,90.75,50,,72.6,percent of total billed charges,50% of total billed charges,90.75,50,,72.6,percent of total billed charges,50% of total billed charges,127.05,70,,101.64,percent of total billed charges,70% of total billed charges,87.99,48.48,,70.392,percent of total billed charges,48.48% of total billed charges,87.99,48.48,,70.392,percent of total billed charges,48.48% of total billed charges,87.99,48.48,,70.392,percent of total billed charges,48.48% of total billed charges,127.05,70,,101.64,percent of total billed charges,70% of total billed charges,127.05,70,,101.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,87.99,48.48,,70.392,percent of total billed charges,48.48% of total billed charges,163.35,90,,130.68,percent of total billed charges,90% of total billed charges,48.48,163.35,
INSERT PICC CATH,36010102,CDM,761,RC,36556,HCPCS,outpatient,,,2384.94,1430.96,,399,100,,,fee schedule,100% of asc tier groupings rate,1144.77,48,,915.816,percent of total billed charges,48% of total billed charges,1338.69,100,,,fee schedule,100% of bcbs custom fee schedule,1338.69,100,,,fee schedule,100% of bcbs custom fee schedule,1485.95,111,,,fee schedule,111% of bcbs custom fee schedule,1192.47,50,,953.976,percent of total billed charges,50% of total billed charges,1669.46,70,,1335.568,percent of total billed charges,70% of total billed charges,1156.22,48.48,,924.976,percent of total billed charges,48.48% of total billed charges,95.1,116.15,,,fee schedule,116.51% of cms physician fee schedule,1156.22,48.48,,924.976,percent of total billed charges,48.48% of total billed charges,1669.46,70,,1335.568,percent of total billed charges,70% of total billed charges,1669.46,70,,1335.568,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,1156.22,48.48,,924.976,percent of total billed charges,48.48% of total billed charges,2146.45,90,,1717.16,percent of total billed charges,90% of total billed charges,48.48,2146.45,
AQUACEL DRESSING 4 X 4,,,270,RC,,,outpatient,,,12.1,7.26,,7.26,60,,5.808,percent of total billed charges,60% of total billed charges,5.81,48,,4.648,percent of total billed charges,48% of total billed charges,6.05,50,,4.84,percent of total billed charges,50% of total billed charges,6.05,50,,4.84,percent of total billed charges,50% of total billed charges,6.05,50,,4.84,percent of total billed charges,50% of total billed charges,6.05,50,,4.84,percent of total billed charges,50% of total billed charges,8.47,70,,6.776,percent of total billed charges,70% of total billed charges,5.87,48.48,,4.696,percent of total billed charges,48.48% of total billed charges,5.87,48.48,,4.696,percent of total billed charges,48.48% of total billed charges,5.87,48.48,,4.696,percent of total billed charges,48.48% of total billed charges,8.47,70,,6.776,percent of total billed charges,70% of total billed charges,8.47,70,,6.776,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,5.87,48.48,,4.696,percent of total billed charges,48.48% of total billed charges,10.89,90,,8.712,percent of total billed charges,90% of total billed charges,5.87,90,
GUMCO SUCTION PER DAY,,,230,RC,,,outpatient,,,275,165.00,,165,60,,132,percent of total billed charges,60% of total billed charges,132,48,,105.6,percent of total billed charges,48% of total billed charges,137.5,50,,110,percent of total billed charges,50% of total billed charges,137.5,50,,110,percent of total billed charges,50% of total billed charges,137.5,50,,110,percent of total billed charges,50% of total billed charges,137.5,50,,110,percent of total billed charges,50% of total billed charges,192.5,70,,154,percent of total billed charges,70% of total billed charges,133.32,48.48,,106.656,percent of total billed charges,48.48% of total billed charges,133.32,48.48,,106.656,percent of total billed charges,48.48% of total billed charges,133.32,48.48,,106.656,percent of total billed charges,48.48% of total billed charges,192.5,70,,154,percent of total billed charges,70% of total billed charges,192.5,70,,154,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,133.32,48.48,,106.656,percent of total billed charges,48.48% of total billed charges,247.5,90,,198,percent of total billed charges,90% of total billed charges,48.48,247.5,
SCD PUMP PER DAY,,,230,RC,,,outpatient,,,125,75.00,,75,60,,60,percent of total billed charges,60% of total billed charges,60,48,,48,percent of total billed charges,48% of total billed charges,62.5,50,,50,percent of total billed charges,50% of total billed charges,62.5,50,,50,percent of total billed charges,50% of total billed charges,62.5,50,,50,percent of total billed charges,50% of total billed charges,62.5,50,,50,percent of total billed charges,50% of total billed charges,87.5,70,,70,percent of total billed charges,70% of total billed charges,60.6,48.48,,48.48,percent of total billed charges,48.48% of total billed charges,60.6,48.48,,48.48,percent of total billed charges,48.48% of total billed charges,60.6,48.48,,48.48,percent of total billed charges,48.48% of total billed charges,87.5,70,,70,percent of total billed charges,70% of total billed charges,87.5,70,,70,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,60.6,48.48,,48.48,percent of total billed charges,48.48% of total billed charges,112.5,90,,90,percent of total billed charges,90% of total billed charges,48.48,112.5,
CLOZEX SKIN CLOSURE 25MM X 35MM,,,270,RC,,,outpatient,,,18.67,11.20,,11.2,60,,8.96,percent of total billed charges,60% of total billed charges,8.96,48,,7.168,percent of total billed charges,48% of total billed charges,9.34,50,,7.472,percent of total billed charges,50% of total billed charges,9.34,50,,7.472,percent of total billed charges,50% of total billed charges,9.34,50,,7.472,percent of total billed charges,50% of total billed charges,9.34,50,,7.472,percent of total billed charges,50% of total billed charges,13.07,70,,10.456,percent of total billed charges,70% of total billed charges,9.05,48.48,,7.24,percent of total billed charges,48.48% of total billed charges,9.05,48.48,,7.24,percent of total billed charges,48.48% of total billed charges,9.05,48.48,,7.24,percent of total billed charges,48.48% of total billed charges,13.07,70,,10.456,percent of total billed charges,70% of total billed charges,13.07,70,,10.456,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.05,48.48,,7.24,percent of total billed charges,48.48% of total billed charges,16.8,90,,13.44,percent of total billed charges,90% of total billed charges,9.05,90,
CLOZEX SKIN CLOSURE 30MM X 35MM,,,270,RC,,,outpatient,,,20.67,12.40,,12.4,60,,9.92,percent of total billed charges,60% of total billed charges,9.92,48,,7.936,percent of total billed charges,48% of total billed charges,10.34,50,,8.272,percent of total billed charges,50% of total billed charges,10.34,50,,8.272,percent of total billed charges,50% of total billed charges,10.34,50,,8.272,percent of total billed charges,50% of total billed charges,10.34,50,,8.272,percent of total billed charges,50% of total billed charges,14.47,70,,11.576,percent of total billed charges,70% of total billed charges,10.02,48.48,,8.016,percent of total billed charges,48.48% of total billed charges,10.02,48.48,,8.016,percent of total billed charges,48.48% of total billed charges,10.02,48.48,,8.016,percent of total billed charges,48.48% of total billed charges,14.47,70,,11.576,percent of total billed charges,70% of total billed charges,14.47,70,,11.576,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,10.02,48.48,,8.016,percent of total billed charges,48.48% of total billed charges,18.6,90,,14.88,percent of total billed charges,90% of total billed charges,10.02,90,
CLOZEX SKIN CLOSURE 40MM X 35MM,,,270,RC,,,outpatient,,,22.67,13.60,,13.6,60,,10.88,percent of total billed charges,60% of total billed charges,10.88,48,,8.704,percent of total billed charges,48% of total billed charges,11.34,50,,9.072,percent of total billed charges,50% of total billed charges,11.34,50,,9.072,percent of total billed charges,50% of total billed charges,11.34,50,,9.072,percent of total billed charges,50% of total billed charges,11.34,50,,9.072,percent of total billed charges,50% of total billed charges,15.87,70,,12.696,percent of total billed charges,70% of total billed charges,10.99,48.48,,8.792,percent of total billed charges,48.48% of total billed charges,10.99,48.48,,8.792,percent of total billed charges,48.48% of total billed charges,10.99,48.48,,8.792,percent of total billed charges,48.48% of total billed charges,15.87,70,,12.696,percent of total billed charges,70% of total billed charges,15.87,70,,12.696,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,10.99,48.48,,8.792,percent of total billed charges,48.48% of total billed charges,20.4,90,,16.32,percent of total billed charges,90% of total billed charges,10.99,90,
CLOZEX SKIN CLOSURE 15MM X 35MM,,,270,RC,,,outpatient,,,13.5,8.10,,8.1,60,,6.48,percent of total billed charges,60% of total billed charges,6.48,48,,5.184,percent of total billed charges,48% of total billed charges,6.75,50,,5.4,percent of total billed charges,50% of total billed charges,6.75,50,,5.4,percent of total billed charges,50% of total billed charges,6.75,50,,5.4,percent of total billed charges,50% of total billed charges,6.75,50,,5.4,percent of total billed charges,50% of total billed charges,9.45,70,,7.56,percent of total billed charges,70% of total billed charges,6.54,48.48,,5.232,percent of total billed charges,48.48% of total billed charges,6.54,48.48,,5.232,percent of total billed charges,48.48% of total billed charges,6.54,48.48,,5.232,percent of total billed charges,48.48% of total billed charges,9.45,70,,7.56,percent of total billed charges,70% of total billed charges,9.45,70,,7.56,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,6.54,48.48,,5.232,percent of total billed charges,48.48% of total billed charges,12.15,90,,9.72,percent of total billed charges,90% of total billed charges,6.54,90,
CLOZEX SKIN CLOSURE 25MM X35MM,,,270,RC,,,outpatient,,,18.5,11.10,,11.1,60,,8.88,percent of total billed charges,60% of total billed charges,8.88,48,,7.104,percent of total billed charges,48% of total billed charges,9.25,50,,7.4,percent of total billed charges,50% of total billed charges,9.25,50,,7.4,percent of total billed charges,50% of total billed charges,9.25,50,,7.4,percent of total billed charges,50% of total billed charges,9.25,50,,7.4,percent of total billed charges,50% of total billed charges,12.95,70,,10.36,percent of total billed charges,70% of total billed charges,8.97,48.48,,7.176,percent of total billed charges,48.48% of total billed charges,8.97,48.48,,7.176,percent of total billed charges,48.48% of total billed charges,8.97,48.48,,7.176,percent of total billed charges,48.48% of total billed charges,12.95,70,,10.36,percent of total billed charges,70% of total billed charges,12.95,70,,10.36,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,8.97,48.48,,7.176,percent of total billed charges,48.48% of total billed charges,16.65,90,,13.32,percent of total billed charges,90% of total billed charges,8.97,90,
CLOZEX SKIN CLOSURE 30MM X 35MM,,,270,RC,,,outpatient,,,20.5,12.30,,12.3,60,,9.84,percent of total billed charges,60% of total billed charges,9.84,48,,7.872,percent of total billed charges,48% of total billed charges,10.25,50,,8.2,percent of total billed charges,50% of total billed charges,10.25,50,,8.2,percent of total billed charges,50% of total billed charges,10.25,50,,8.2,percent of total billed charges,50% of total billed charges,10.25,50,,8.2,percent of total billed charges,50% of total billed charges,14.35,70,,11.48,percent of total billed charges,70% of total billed charges,9.94,48.48,,7.952,percent of total billed charges,48.48% of total billed charges,9.94,48.48,,7.952,percent of total billed charges,48.48% of total billed charges,9.94,48.48,,7.952,percent of total billed charges,48.48% of total billed charges,14.35,70,,11.48,percent of total billed charges,70% of total billed charges,14.35,70,,11.48,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.94,48.48,,7.952,percent of total billed charges,48.48% of total billed charges,18.45,90,,14.76,percent of total billed charges,90% of total billed charges,9.94,90,
CLOZEX SKIN CLOSURE 40MM X 35MM,,,270,RC,,,outpatient,,,23.8,14.28,,14.28,60,,11.424,percent of total billed charges,60% of total billed charges,11.42,48,,9.136,percent of total billed charges,48% of total billed charges,11.9,50,,9.52,percent of total billed charges,50% of total billed charges,11.9,50,,9.52,percent of total billed charges,50% of total billed charges,11.9,50,,9.52,percent of total billed charges,50% of total billed charges,11.9,50,,9.52,percent of total billed charges,50% of total billed charges,16.66,70,,13.328,percent of total billed charges,70% of total billed charges,11.54,48.48,,9.232,percent of total billed charges,48.48% of total billed charges,11.54,48.48,,9.232,percent of total billed charges,48.48% of total billed charges,11.54,48.48,,9.232,percent of total billed charges,48.48% of total billed charges,16.66,70,,13.328,percent of total billed charges,70% of total billed charges,16.66,70,,13.328,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,11.54,48.48,,9.232,percent of total billed charges,48.48% of total billed charges,21.42,90,,17.136,percent of total billed charges,90% of total billed charges,11.54,90,
CLOZEX SKIN CLOSURE 40MM X 50MM,,,270,RC,,,outpatient,,,23.8,14.28,,14.28,60,,11.424,percent of total billed charges,60% of total billed charges,11.42,48,,9.136,percent of total billed charges,48% of total billed charges,11.9,50,,9.52,percent of total billed charges,50% of total billed charges,11.9,50,,9.52,percent of total billed charges,50% of total billed charges,11.9,50,,9.52,percent of total billed charges,50% of total billed charges,11.9,50,,9.52,percent of total billed charges,50% of total billed charges,16.66,70,,13.328,percent of total billed charges,70% of total billed charges,11.54,48.48,,9.232,percent of total billed charges,48.48% of total billed charges,11.54,48.48,,9.232,percent of total billed charges,48.48% of total billed charges,11.54,48.48,,9.232,percent of total billed charges,48.48% of total billed charges,16.66,70,,13.328,percent of total billed charges,70% of total billed charges,16.66,70,,13.328,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,11.54,48.48,,9.232,percent of total billed charges,48.48% of total billed charges,21.42,90,,17.136,percent of total billed charges,90% of total billed charges,11.54,90,
CLOZEX SKIN CLOSURE 50MM X 50MM,,,270,RC,,,outpatient,,,27.5,16.50,,16.5,60,,13.2,percent of total billed charges,60% of total billed charges,13.2,48,,10.56,percent of total billed charges,48% of total billed charges,13.75,50,,11,percent of total billed charges,50% of total billed charges,13.75,50,,11,percent of total billed charges,50% of total billed charges,13.75,50,,11,percent of total billed charges,50% of total billed charges,13.75,50,,11,percent of total billed charges,50% of total billed charges,19.25,70,,15.4,percent of total billed charges,70% of total billed charges,13.33,48.48,,10.664,percent of total billed charges,48.48% of total billed charges,13.33,48.48,,10.664,percent of total billed charges,48.48% of total billed charges,13.33,48.48,,10.664,percent of total billed charges,48.48% of total billed charges,19.25,70,,15.4,percent of total billed charges,70% of total billed charges,19.25,70,,15.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,13.33,48.48,,10.664,percent of total billed charges,48.48% of total billed charges,24.75,90,,19.8,percent of total billed charges,90% of total billed charges,13.33,90,
CLOZEX SKIN CLOSURE 60MM X 50MM,,,270,RC,,,outpatient,,,31,18.60,,18.6,60,,14.88,percent of total billed charges,60% of total billed charges,14.88,48,,11.904,percent of total billed charges,48% of total billed charges,15.5,50,,12.4,percent of total billed charges,50% of total billed charges,15.5,50,,12.4,percent of total billed charges,50% of total billed charges,15.5,50,,12.4,percent of total billed charges,50% of total billed charges,15.5,50,,12.4,percent of total billed charges,50% of total billed charges,21.7,70,,17.36,percent of total billed charges,70% of total billed charges,15.03,48.48,,12.024,percent of total billed charges,48.48% of total billed charges,15.03,48.48,,12.024,percent of total billed charges,48.48% of total billed charges,15.03,48.48,,12.024,percent of total billed charges,48.48% of total billed charges,21.7,70,,17.36,percent of total billed charges,70% of total billed charges,21.7,70,,17.36,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,15.03,48.48,,12.024,percent of total billed charges,48.48% of total billed charges,27.9,90,,22.32,percent of total billed charges,90% of total billed charges,15.03,90,
CLOZEX SKIN CLOSURE 80MM X 50MM,,,270,RC,,,outpatient,,,34.5,20.70,,20.7,60,,16.56,percent of total billed charges,60% of total billed charges,16.56,48,,13.248,percent of total billed charges,48% of total billed charges,17.25,50,,13.8,percent of total billed charges,50% of total billed charges,17.25,50,,13.8,percent of total billed charges,50% of total billed charges,17.25,50,,13.8,percent of total billed charges,50% of total billed charges,17.25,50,,13.8,percent of total billed charges,50% of total billed charges,24.15,70,,19.32,percent of total billed charges,70% of total billed charges,16.73,48.48,,13.384,percent of total billed charges,48.48% of total billed charges,16.73,48.48,,13.384,percent of total billed charges,48.48% of total billed charges,16.73,48.48,,13.384,percent of total billed charges,48.48% of total billed charges,24.15,70,,19.32,percent of total billed charges,70% of total billed charges,24.15,70,,19.32,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,16.73,48.48,,13.384,percent of total billed charges,48.48% of total billed charges,31.05,90,,24.84,percent of total billed charges,90% of total billed charges,16.73,90,
CLOZEX SKIN CLOSURE 100MM X 50MM,,,270,RC,,,outpatient,,,38,22.80,,22.8,60,,18.24,percent of total billed charges,60% of total billed charges,18.24,48,,14.592,percent of total billed charges,48% of total billed charges,19,50,,15.2,percent of total billed charges,50% of total billed charges,19,50,,15.2,percent of total billed charges,50% of total billed charges,19,50,,15.2,percent of total billed charges,50% of total billed charges,19,50,,15.2,percent of total billed charges,50% of total billed charges,26.6,70,,21.28,percent of total billed charges,70% of total billed charges,18.42,48.48,,14.736,percent of total billed charges,48.48% of total billed charges,18.42,48.48,,14.736,percent of total billed charges,48.48% of total billed charges,18.42,48.48,,14.736,percent of total billed charges,48.48% of total billed charges,26.6,70,,21.28,percent of total billed charges,70% of total billed charges,26.6,70,,21.28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,18.42,48.48,,14.736,percent of total billed charges,48.48% of total billed charges,34.2,90,,27.36,percent of total billed charges,90% of total billed charges,18.42,90,
KERLIX 3" KLING,,,270,RC,A6446,HCPCS,outpatient,,,11,6.60,,6.6,60,,5.28,percent of total billed charges,60% of total billed charges,5.28,48,,4.224,percent of total billed charges,48% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,9.9,90,,7.92,percent of total billed charges,90% of total billed charges,5.33,90,
VASELINE GAUZE 3X8 BX.,,,270,RC,A6223,HCPCS,outpatient,,,16.34,9.80,,9.8,60,,7.84,percent of total billed charges,60% of total billed charges,7.84,48,,6.272,percent of total billed charges,48% of total billed charges,8.17,50,,6.536,percent of total billed charges,50% of total billed charges,8.17,50,,6.536,percent of total billed charges,50% of total billed charges,8.17,50,,6.536,percent of total billed charges,50% of total billed charges,8.17,50,,6.536,percent of total billed charges,50% of total billed charges,11.44,70,,9.152,percent of total billed charges,70% of total billed charges,7.92,48.48,,6.336,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,7.92,48.48,,6.336,percent of total billed charges,48.48% of total billed charges,11.44,70,,9.152,percent of total billed charges,70% of total billed charges,11.44,70,,9.152,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,7.92,48.48,,6.336,percent of total billed charges,48.48% of total billed charges,14.71,90,,11.768,percent of total billed charges,90% of total billed charges,7.92,90,
HYDRASORB 4 X 8 BOX,,,270,RC,,,outpatient,,,40.36,24.22,,24.22,60,,19.376,percent of total billed charges,60% of total billed charges,19.37,48,,15.496,percent of total billed charges,48% of total billed charges,20.18,50,,16.144,percent of total billed charges,50% of total billed charges,20.18,50,,16.144,percent of total billed charges,50% of total billed charges,20.18,50,,16.144,percent of total billed charges,50% of total billed charges,20.18,50,,16.144,percent of total billed charges,50% of total billed charges,28.25,70,,22.6,percent of total billed charges,70% of total billed charges,19.57,48.48,,15.656,percent of total billed charges,48.48% of total billed charges,19.57,48.48,,15.656,percent of total billed charges,48.48% of total billed charges,19.57,48.48,,15.656,percent of total billed charges,48.48% of total billed charges,28.25,70,,22.6,percent of total billed charges,70% of total billed charges,28.25,70,,22.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,19.57,48.48,,15.656,percent of total billed charges,48.48% of total billed charges,36.32,90,,29.056,percent of total billed charges,90% of total billed charges,19.57,90,
"Cath, Foley 8 FR 3CC",,,270,RC,A6446,HCPCS,outpatient,,,43.4,26.04,,26.04,60,,20.832,percent of total billed charges,60% of total billed charges,20.83,48,,16.664,percent of total billed charges,48% of total billed charges,21.7,50,,17.36,percent of total billed charges,50% of total billed charges,21.7,50,,17.36,percent of total billed charges,50% of total billed charges,21.7,50,,17.36,percent of total billed charges,50% of total billed charges,21.7,50,,17.36,percent of total billed charges,50% of total billed charges,30.38,70,,24.304,percent of total billed charges,70% of total billed charges,21.04,48.48,,16.832,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,21.04,48.48,,16.832,percent of total billed charges,48.48% of total billed charges,30.38,70,,24.304,percent of total billed charges,70% of total billed charges,30.38,70,,24.304,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,21.04,48.48,,16.832,percent of total billed charges,48.48% of total billed charges,39.06,90,,31.248,percent of total billed charges,90% of total billed charges,21.04,90,
"Cath, Foley 20 FR 5CC",,,270,RC,A6446,HCPCS,outpatient,,,55,33.00,,33,60,,26.4,percent of total billed charges,60% of total billed charges,26.4,48,,21.12,percent of total billed charges,48% of total billed charges,27.5,50,,22,percent of total billed charges,50% of total billed charges,27.5,50,,22,percent of total billed charges,50% of total billed charges,27.5,50,,22,percent of total billed charges,50% of total billed charges,27.5,50,,22,percent of total billed charges,50% of total billed charges,38.5,70,,30.8,percent of total billed charges,70% of total billed charges,26.66,48.48,,21.328,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,26.66,48.48,,21.328,percent of total billed charges,48.48% of total billed charges,38.5,70,,30.8,percent of total billed charges,70% of total billed charges,38.5,70,,30.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,26.66,48.48,,21.328,percent of total billed charges,48.48% of total billed charges,49.5,90,,39.6,percent of total billed charges,90% of total billed charges,26.66,90,
KERLIX 4" KLING,,,270,RC,A6446,HCPCS,outpatient,,,11,6.60,,6.6,60,,5.28,percent of total billed charges,60% of total billed charges,5.28,48,,4.224,percent of total billed charges,48% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,9.9,90,,7.92,percent of total billed charges,90% of total billed charges,5.33,90,
DRAINAGE DRESSING KIT,,,279,RC,,,outpatient,,,15.49,9.29,,9.29,60,,7.432,percent of total billed charges,60% of total billed charges,7.44,48,,5.952,percent of total billed charges,48% of total billed charges,7.75,50,,6.2,percent of total billed charges,50% of total billed charges,7.75,50,,6.2,percent of total billed charges,50% of total billed charges,7.75,50,,6.2,percent of total billed charges,50% of total billed charges,7.75,50,,6.2,percent of total billed charges,50% of total billed charges,10.84,70,,8.672,percent of total billed charges,70% of total billed charges,7.51,48.48,,6.008,percent of total billed charges,48.48% of total billed charges,7.51,48.48,,6.008,percent of total billed charges,48.48% of total billed charges,7.51,48.48,,6.008,percent of total billed charges,48.48% of total billed charges,10.84,70,,8.672,percent of total billed charges,70% of total billed charges,10.84,70,,8.672,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,7.51,48.48,,6.008,percent of total billed charges,48.48% of total billed charges,13.94,90,,11.152,percent of total billed charges,90% of total billed charges,7.51,90,
ADAPTIC DRESSING 3X8,,,270,RC,,,outpatient,,,12.1,7.26,,7.26,60,,5.808,percent of total billed charges,60% of total billed charges,5.81,48,,4.648,percent of total billed charges,48% of total billed charges,6.05,50,,4.84,percent of total billed charges,50% of total billed charges,6.05,50,,4.84,percent of total billed charges,50% of total billed charges,6.05,50,,4.84,percent of total billed charges,50% of total billed charges,6.05,50,,4.84,percent of total billed charges,50% of total billed charges,8.47,70,,6.776,percent of total billed charges,70% of total billed charges,5.87,48.48,,4.696,percent of total billed charges,48.48% of total billed charges,5.87,48.48,,4.696,percent of total billed charges,48.48% of total billed charges,5.87,48.48,,4.696,percent of total billed charges,48.48% of total billed charges,8.47,70,,6.776,percent of total billed charges,70% of total billed charges,8.47,70,,6.776,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,5.87,48.48,,4.696,percent of total billed charges,48.48% of total billed charges,10.89,90,,8.712,percent of total billed charges,90% of total billed charges,5.87,90,
ARM SLING REGULAR,,,274,RC,,,outpatient,,,26.4,15.84,,15.84,60,,12.672,percent of total billed charges,60% of total billed charges,12.67,48,,10.136,percent of total billed charges,48% of total billed charges,13.2,50,,10.56,percent of total billed charges,50% of total billed charges,13.2,50,,10.56,percent of total billed charges,50% of total billed charges,13.2,50,,10.56,percent of total billed charges,50% of total billed charges,13.2,50,,10.56,percent of total billed charges,50% of total billed charges,18.48,70,,14.784,percent of total billed charges,70% of total billed charges,12.8,48.48,,10.24,percent of total billed charges,48.48% of total billed charges,12.8,48.48,,10.24,percent of total billed charges,48.48% of total billed charges,12.8,48.48,,10.24,percent of total billed charges,48.48% of total billed charges,18.48,70,,14.784,percent of total billed charges,70% of total billed charges,18.48,70,,14.784,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,12.8,48.48,,10.24,percent of total billed charges,48.48% of total billed charges,23.76,90,,19.008,percent of total billed charges,90% of total billed charges,12.8,90,
ARM SLING WITH SWATH,,,270,RC,,,outpatient,,,45.44,27.26,,27.26,60,,21.808,percent of total billed charges,60% of total billed charges,21.81,48,,17.448,percent of total billed charges,48% of total billed charges,22.72,50,,18.176,percent of total billed charges,50% of total billed charges,22.72,50,,18.176,percent of total billed charges,50% of total billed charges,22.72,50,,18.176,percent of total billed charges,50% of total billed charges,22.72,50,,18.176,percent of total billed charges,50% of total billed charges,31.81,70,,25.448,percent of total billed charges,70% of total billed charges,22.03,48.48,,17.624,percent of total billed charges,48.48% of total billed charges,22.03,48.48,,17.624,percent of total billed charges,48.48% of total billed charges,22.03,48.48,,17.624,percent of total billed charges,48.48% of total billed charges,31.81,70,,25.448,percent of total billed charges,70% of total billed charges,31.81,70,,25.448,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,22.03,48.48,,17.624,percent of total billed charges,48.48% of total billed charges,40.9,90,,32.72,percent of total billed charges,90% of total billed charges,22.03,90,
UNNA BOOT,43601396,CDM,761,RC,29580,HCPCS,outpatient,,,357.72,214.63,GP,214.63,60,,171.704,percent of total billed charges,60% of total billed charges,171.71,48,,137.368,percent of total billed charges,48% of total billed charges,325.87,100,,,fee schedule,100% of bcbs custom fee schedule,325.87,100,,,fee schedule,100% of bcbs custom fee schedule,361.72,111,,,fee schedule,111% of bcbs custom fee schedule,178.86,50,,143.088,percent of total billed charges,50% of total billed charges,250.4,70,,200.32,percent of total billed charges,70% of total billed charges,173.42,48.48,,138.736,percent of total billed charges,48.48% of total billed charges,29.77,116.15,,,fee schedule,116.51% of cms physician fee schedule,173.42,48.48,,138.736,percent of total billed charges,48.48% of total billed charges,250.4,70,,200.32,percent of total billed charges,70% of total billed charges,250.4,70,,200.32,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,173.42,48.48,,138.736,percent of total billed charges,48.48% of total billed charges,321.95,90,,257.56,percent of total billed charges,90% of total billed charges,48.48,321.95,
APPLY MULTLAY COMPRS LWR LEG,44500077,CDM,761,RC,29581,HCPCS,outpatient,,,357.72,214.63,,214.63,60,,171.704,percent of total billed charges,60% of total billed charges,171.71,48,,137.368,percent of total billed charges,48% of total billed charges,194.12,100,,,fee schedule,100% of bcbs custom fee schedule,194.12,100,,,fee schedule,100% of bcbs custom fee schedule,215.47,111,,,fee schedule,111% of bcbs custom fee schedule,178.86,50,,143.088,percent of total billed charges,50% of total billed charges,250.4,70,,200.32,percent of total billed charges,70% of total billed charges,173.42,48.48,,138.736,percent of total billed charges,48.48% of total billed charges,29.73,116.15,,,fee schedule,116.51% of cms physician fee schedule,173.42,48.48,,138.736,percent of total billed charges,48.48% of total billed charges,250.4,70,,200.32,percent of total billed charges,70% of total billed charges,250.4,70,,200.32,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,173.42,48.48,,138.736,percent of total billed charges,48.48% of total billed charges,321.95,90,,257.56,percent of total billed charges,90% of total billed charges,48.48,321.95,
DRESS/DEBRID P-THICK BURN L,36010028,CDM,761,RC,16030,HCPCS,outpatient,,,676.65,405.99,,535,100,,,fee schedule,100% of asc tier groupings rate,324.79,48,,259.832,percent of total billed charges,48% of total billed charges,338.33,50,,270.664,percent of total billed charges,50% of total billed charges,338.33,50,,270.664,percent of total billed charges,50% of total billed charges,338.33,50,,270.664,percent of total billed charges,50% of total billed charges,338.33,50,,270.664,percent of total billed charges,50% of total billed charges,473.66,70,,378.928,percent of total billed charges,70% of total billed charges,328.04,48.48,,262.432,percent of total billed charges,48.48% of total billed charges,148.1,116.15,,,fee schedule,116.51% of cms physician fee schedule,328.04,48.48,,262.432,percent of total billed charges,48.48% of total billed charges,473.66,70,,378.928,percent of total billed charges,70% of total billed charges,473.66,70,,378.928,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,328.04,48.48,,262.432,percent of total billed charges,48.48% of total billed charges,608.99,90,,487.192,percent of total billed charges,90% of total billed charges,48.48,608.99,
IMMOBILIZER SHOULDER SMALL,,,273,RC,,,outpatient,,,10.63,6.38,,6.38,60,,5.104,percent of total billed charges,60% of total billed charges,5.1,48,,4.08,percent of total billed charges,48% of total billed charges,5.32,50,,4.256,percent of total billed charges,50% of total billed charges,5.32,50,,4.256,percent of total billed charges,50% of total billed charges,5.32,50,,4.256,percent of total billed charges,50% of total billed charges,5.32,50,,4.256,percent of total billed charges,50% of total billed charges,7.44,70,,5.952,percent of total billed charges,70% of total billed charges,5.15,48.48,,4.12,percent of total billed charges,48.48% of total billed charges,5.15,48.48,,4.12,percent of total billed charges,48.48% of total billed charges,5.15,48.48,,4.12,percent of total billed charges,48.48% of total billed charges,7.44,70,,5.952,percent of total billed charges,70% of total billed charges,7.44,70,,5.952,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,5.15,48.48,,4.12,percent of total billed charges,48.48% of total billed charges,9.57,90,,7.656,percent of total billed charges,90% of total billed charges,5.15,90,
IMMOBILIZER SHOULDER XLARGE,,,273,RC,,,outpatient,,,10.65,6.39,,6.39,60,,5.112,percent of total billed charges,60% of total billed charges,5.11,48,,4.088,percent of total billed charges,48% of total billed charges,5.33,50,,4.264,percent of total billed charges,50% of total billed charges,5.33,50,,4.264,percent of total billed charges,50% of total billed charges,5.33,50,,4.264,percent of total billed charges,50% of total billed charges,5.33,50,,4.264,percent of total billed charges,50% of total billed charges,7.46,70,,5.968,percent of total billed charges,70% of total billed charges,5.16,48.48,,4.128,percent of total billed charges,48.48% of total billed charges,5.16,48.48,,4.128,percent of total billed charges,48.48% of total billed charges,5.16,48.48,,4.128,percent of total billed charges,48.48% of total billed charges,7.46,70,,5.968,percent of total billed charges,70% of total billed charges,7.46,70,,5.968,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,5.16,48.48,,4.128,percent of total billed charges,48.48% of total billed charges,9.59,90,,7.672,percent of total billed charges,90% of total billed charges,5.16,90,
IMMOBILIZER SHOULDER LARGE,,,273,RC,,,outpatient,,,23.86,14.32,,14.32,60,,11.456,percent of total billed charges,60% of total billed charges,11.45,48,,9.16,percent of total billed charges,48% of total billed charges,11.93,50,,9.544,percent of total billed charges,50% of total billed charges,11.93,50,,9.544,percent of total billed charges,50% of total billed charges,11.93,50,,9.544,percent of total billed charges,50% of total billed charges,11.93,50,,9.544,percent of total billed charges,50% of total billed charges,16.7,70,,13.36,percent of total billed charges,70% of total billed charges,11.57,48.48,,9.256,percent of total billed charges,48.48% of total billed charges,11.57,48.48,,9.256,percent of total billed charges,48.48% of total billed charges,11.57,48.48,,9.256,percent of total billed charges,48.48% of total billed charges,16.7,70,,13.36,percent of total billed charges,70% of total billed charges,16.7,70,,13.36,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,11.57,48.48,,9.256,percent of total billed charges,48.48% of total billed charges,21.47,90,,17.176,percent of total billed charges,90% of total billed charges,11.57,90,
IMMOBILIZER SHOULDER MED,,,273,RC,,,outpatient,,,23.86,14.32,,14.32,60,,11.456,percent of total billed charges,60% of total billed charges,11.45,48,,9.16,percent of total billed charges,48% of total billed charges,11.93,50,,9.544,percent of total billed charges,50% of total billed charges,11.93,50,,9.544,percent of total billed charges,50% of total billed charges,11.93,50,,9.544,percent of total billed charges,50% of total billed charges,11.93,50,,9.544,percent of total billed charges,50% of total billed charges,16.7,70,,13.36,percent of total billed charges,70% of total billed charges,11.57,48.48,,9.256,percent of total billed charges,48.48% of total billed charges,11.57,48.48,,9.256,percent of total billed charges,48.48% of total billed charges,11.57,48.48,,9.256,percent of total billed charges,48.48% of total billed charges,16.7,70,,13.36,percent of total billed charges,70% of total billed charges,16.7,70,,13.36,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,11.57,48.48,,9.256,percent of total billed charges,48.48% of total billed charges,21.47,90,,17.176,percent of total billed charges,90% of total billed charges,11.57,90,
CPAP FULL MASK HEADGEAR MED/LG,,,279,RC,,,outpatient,,,26.82,16.09,,16.09,60,,12.872,percent of total billed charges,60% of total billed charges,12.87,48,,10.296,percent of total billed charges,48% of total billed charges,13.41,50,,10.728,percent of total billed charges,50% of total billed charges,13.41,50,,10.728,percent of total billed charges,50% of total billed charges,13.41,50,,10.728,percent of total billed charges,50% of total billed charges,13.41,50,,10.728,percent of total billed charges,50% of total billed charges,18.77,70,,15.016,percent of total billed charges,70% of total billed charges,13,48.48,,10.4,percent of total billed charges,48.48% of total billed charges,13,48.48,,10.4,percent of total billed charges,48.48% of total billed charges,13,48.48,,10.4,percent of total billed charges,48.48% of total billed charges,18.77,70,,15.016,percent of total billed charges,70% of total billed charges,18.77,70,,15.016,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,13,48.48,,10.4,percent of total billed charges,48.48% of total billed charges,24.14,90,,19.312,percent of total billed charges,90% of total billed charges,13,90,
MIDLINE PLACEMENT,32001000,CDM,761,RC,36569,HCPCS,outpatient,,,1156.05,693.63,,399,100,,,fee schedule,100% of asc tier groupings rate,554.9,48,,443.92,percent of total billed charges,48% of total billed charges,1338.69,100,,,fee schedule,100% of bcbs custom fee schedule,1338.69,100,,,fee schedule,100% of bcbs custom fee schedule,1485.95,111,,,fee schedule,111% of bcbs custom fee schedule,578.03,50,,462.424,percent of total billed charges,50% of total billed charges,809.24,70,,647.392,percent of total billed charges,70% of total billed charges,560.45,48.48,,448.36,percent of total billed charges,48.48% of total billed charges,106.6,116.15,,,fee schedule,116.51% of cms physician fee schedule,560.45,48.48,,448.36,percent of total billed charges,48.48% of total billed charges,809.24,70,,647.392,percent of total billed charges,70% of total billed charges,809.24,70,,647.392,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,560.45,48.48,,448.36,percent of total billed charges,48.48% of total billed charges,1040.45,90,,832.36,percent of total billed charges,90% of total billed charges,48.48,1040.45,
High Flow NC Procedure,43102014,CDM,410,RC,94799,HCPCS,outpatient,,,149.95,89.97,,89.97,60,,71.976,percent of total billed charges,60% of total billed charges,71.98,48,,57.584,percent of total billed charges,48% of total billed charges,85.61,100,,,fee schedule,100% of bcbs custom fee schedule,85.61,100,,,fee schedule,100% of bcbs custom fee schedule,95.03,111,,,fee schedule,111% of bcbs custom fee schedule,80,100,,,case rate,pays based on per visit rate,104.97,70,,83.976,percent of total billed charges,70% of total billed charges,72.7,48.48,,58.16,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,72.7,48.48,,58.16,percent of total billed charges,48.48% of total billed charges,104.97,70,,83.976,percent of total billed charges,70% of total billed charges,104.97,70,,83.976,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,72.7,48.48,,58.16,percent of total billed charges,48.48% of total billed charges,134.96,90,,107.968,percent of total billed charges,90% of total billed charges,48.48,134.96,
Cast Padding 4",,,270,RC,Q4050,HCPCS,outpatient,,,12.54,7.52,,7.52,60,,6.016,percent of total billed charges,60% of total billed charges,6.02,48,,4.816,percent of total billed charges,48% of total billed charges,6.27,50,,5.016,percent of total billed charges,50% of total billed charges,6.27,50,,5.016,percent of total billed charges,50% of total billed charges,6.27,50,,5.016,percent of total billed charges,50% of total billed charges,6.27,50,,5.016,percent of total billed charges,50% of total billed charges,8.78,70,,7.024,percent of total billed charges,70% of total billed charges,6.08,48.48,,4.864,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,6.08,48.48,,4.864,percent of total billed charges,48.48% of total billed charges,8.78,70,,7.024,percent of total billed charges,70% of total billed charges,8.78,70,,7.024,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,6.08,48.48,,4.864,percent of total billed charges,48.48% of total billed charges,11.29,90,,9.032,percent of total billed charges,90% of total billed charges,6.08,90,
Cast Padding 3",,,270,RC,Q4050,HCPCS,outpatient,,,12.54,7.52,,7.52,60,,6.016,percent of total billed charges,60% of total billed charges,6.02,48,,4.816,percent of total billed charges,48% of total billed charges,6.27,50,,5.016,percent of total billed charges,50% of total billed charges,6.27,50,,5.016,percent of total billed charges,50% of total billed charges,6.27,50,,5.016,percent of total billed charges,50% of total billed charges,6.27,50,,5.016,percent of total billed charges,50% of total billed charges,8.78,70,,7.024,percent of total billed charges,70% of total billed charges,6.08,48.48,,4.864,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,6.08,48.48,,4.864,percent of total billed charges,48.48% of total billed charges,8.78,70,,7.024,percent of total billed charges,70% of total billed charges,8.78,70,,7.024,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,6.08,48.48,,4.864,percent of total billed charges,48.48% of total billed charges,11.29,90,,9.032,percent of total billed charges,90% of total billed charges,6.08,90,
EXC MAL LESION S/N/H/F/G 2.1-3.0 CM,,,761,RC,11623,HCPCS,outpatient,,,720.13,432.08,,399,100,,,fee schedule,100% of asc tier groupings rate,345.66,48,,276.528,percent of total billed charges,48% of total billed charges,2439.28,100,,,fee schedule,100% of bcbs custom fee schedule,2439.28,100,,,fee schedule,100% of bcbs custom fee schedule,2707.6,111,,,fee schedule,111% of bcbs custom fee schedule,360.07,50,,288.056,percent of total billed charges,50% of total billed charges,504.09,70,,403.272,percent of total billed charges,70% of total billed charges,349.12,48.48,,279.296,percent of total billed charges,48.48% of total billed charges,230.73,116.15,,,fee schedule,116.51% of cms physician fee schedule,349.12,48.48,,279.296,percent of total billed charges,48.48% of total billed charges,504.09,70,,403.272,percent of total billed charges,70% of total billed charges,504.09,70,,403.272,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,349.12,48.48,,279.296,percent of total billed charges,48.48% of total billed charges,648.12,90,,518.496,percent of total billed charges,90% of total billed charges,48.48,648.12,
STATLOCK PICC STABILIZATION DEVICE,,,279,RC,,,outpatient,,,29.5,17.70,,17.7,60,,14.16,percent of total billed charges,60% of total billed charges,14.16,48,,11.328,percent of total billed charges,48% of total billed charges,14.75,50,,11.8,percent of total billed charges,50% of total billed charges,14.75,50,,11.8,percent of total billed charges,50% of total billed charges,14.75,50,,11.8,percent of total billed charges,50% of total billed charges,14.75,50,,11.8,percent of total billed charges,50% of total billed charges,20.65,70,,16.52,percent of total billed charges,70% of total billed charges,14.3,48.48,,11.44,percent of total billed charges,48.48% of total billed charges,14.3,48.48,,11.44,percent of total billed charges,48.48% of total billed charges,14.3,48.48,,11.44,percent of total billed charges,48.48% of total billed charges,20.65,70,,16.52,percent of total billed charges,70% of total billed charges,20.65,70,,16.52,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,14.3,48.48,,11.44,percent of total billed charges,48.48% of total billed charges,26.55,90,,21.24,percent of total billed charges,90% of total billed charges,14.3,90,
TEGADERM DRESSING 4X4,,,279,RC,A6257,HCPCS,outpatient,,,10.56,6.34,,6.34,60,,5.072,percent of total billed charges,60% of total billed charges,5.07,48,,4.056,percent of total billed charges,48% of total billed charges,5.28,50,,4.224,percent of total billed charges,50% of total billed charges,5.28,50,,4.224,percent of total billed charges,50% of total billed charges,5.28,50,,4.224,percent of total billed charges,50% of total billed charges,5.28,50,,4.224,percent of total billed charges,50% of total billed charges,7.39,70,,5.912,percent of total billed charges,70% of total billed charges,5.12,48.48,,4.096,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,5.12,48.48,,4.096,percent of total billed charges,48.48% of total billed charges,7.39,70,,5.912,percent of total billed charges,70% of total billed charges,7.39,70,,5.912,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,5.12,48.48,,4.096,percent of total billed charges,48.48% of total billed charges,9.5,90,,7.6,percent of total billed charges,90% of total billed charges,5.12,90,
"DRSG, HYDROCOLLOID 4X4",,,279,RC,,,outpatient,,,22.06,13.24,,13.24,60,,10.592,percent of total billed charges,60% of total billed charges,10.59,48,,8.472,percent of total billed charges,48% of total billed charges,11.03,50,,8.824,percent of total billed charges,50% of total billed charges,11.03,50,,8.824,percent of total billed charges,50% of total billed charges,11.03,50,,8.824,percent of total billed charges,50% of total billed charges,11.03,50,,8.824,percent of total billed charges,50% of total billed charges,15.44,70,,12.352,percent of total billed charges,70% of total billed charges,10.69,48.48,,8.552,percent of total billed charges,48.48% of total billed charges,10.69,48.48,,8.552,percent of total billed charges,48.48% of total billed charges,10.69,48.48,,8.552,percent of total billed charges,48.48% of total billed charges,15.44,70,,12.352,percent of total billed charges,70% of total billed charges,15.44,70,,12.352,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,10.69,48.48,,8.552,percent of total billed charges,48.48% of total billed charges,19.85,90,,15.88,percent of total billed charges,90% of total billed charges,10.69,90,
ALBUMIN SERUM/PLSMA/ WBLD,41000021,CDM,301,RC,82040,HCPCS,outpatient,,,35,21.00,,21,60,,16.8,percent of total billed charges,60% of total billed charges,16.8,48,,13.44,percent of total billed charges,48% of total billed charges,15,100,,,fee schedule,100% of bcbs custom fee schedule,15,100,,,fee schedule,100% of bcbs custom fee schedule,16.65,111,,,fee schedule,111% of bcbs custom fee schedule,17.5,50,,14,percent of total billed charges,50% of total billed charges,24.5,70,,19.6,percent of total billed charges,70% of total billed charges,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,5,101,,,fee schedule,101% of cms custom fee schedule,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,24.5,70,,19.6,percent of total billed charges,70% of total billed charges,24.5,70,,19.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,31.5,90,,25.2,percent of total billed charges,90% of total billed charges,16.97,90,
FERRITIN,41000414,CDM,300,RC,82728,HCPCS,outpatient,,,93.75,56.25,,56.25,60,,45,percent of total billed charges,60% of total billed charges,45,48,,36,percent of total billed charges,48% of total billed charges,41.25,100,,,fee schedule,100% of bcbs custom fee schedule,41.25,100,,,fee schedule,100% of bcbs custom fee schedule,45.79,111,,,fee schedule,111% of bcbs custom fee schedule,46.88,50,,37.504,percent of total billed charges,50% of total billed charges,65.63,70,,52.504,percent of total billed charges,70% of total billed charges,45.45,48.48,,36.36,percent of total billed charges,48.48% of total billed charges,13.77,101,,,fee schedule,101% of cms custom fee schedule,45.45,48.48,,36.36,percent of total billed charges,48.48% of total billed charges,65.63,70,,52.504,percent of total billed charges,70% of total billed charges,65.63,70,,52.504,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,45.45,48.48,,36.36,percent of total billed charges,48.48% of total billed charges,84.38,90,,67.504,percent of total billed charges,90% of total billed charges,45.45,90,
ALKALINE PHOSPHATASE,41000003,CDM,301,RC,84075,HCPCS,outpatient,,,68,40.80,,40.8,60,,32.64,percent of total billed charges,60% of total billed charges,32.64,48,,26.112,percent of total billed charges,48% of total billed charges,15.67,100,,,fee schedule,100% of bcbs custom fee schedule,15.67,100,,,fee schedule,100% of bcbs custom fee schedule,17.39,111,,,fee schedule,111% of bcbs custom fee schedule,34,50,,27.2,percent of total billed charges,50% of total billed charges,47.6,70,,38.08,percent of total billed charges,70% of total billed charges,32.97,48.48,,26.376,percent of total billed charges,48.48% of total billed charges,5.23,101,,,fee schedule,101% of cms custom fee schedule,32.97,48.48,,26.376,percent of total billed charges,48.48% of total billed charges,47.6,70,,38.08,percent of total billed charges,70% of total billed charges,47.6,70,,38.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,32.97,48.48,,26.376,percent of total billed charges,48.48% of total billed charges,61.2,90,,48.96,percent of total billed charges,90% of total billed charges,32.97,90,
THYROID STIMULATING HORMONE,41000229,CDM,300,RC,84443,HCPCS,outpatient,,,121.5,72.90,,72.9,60,,58.32,percent of total billed charges,60% of total billed charges,58.32,48,,46.656,percent of total billed charges,48% of total billed charges,50.88,100,,,fee schedule,100% of bcbs custom fee schedule,50.88,100,,,fee schedule,100% of bcbs custom fee schedule,56.48,111,,,fee schedule,111% of bcbs custom fee schedule,60.75,50,,48.6,percent of total billed charges,50% of total billed charges,85.05,70,,68.04,percent of total billed charges,70% of total billed charges,58.9,48.48,,47.12,percent of total billed charges,48.48% of total billed charges,16.97,101,,,fee schedule,101% of cms custom fee schedule,58.9,48.48,,47.12,percent of total billed charges,48.48% of total billed charges,85.05,70,,68.04,percent of total billed charges,70% of total billed charges,85.05,70,,68.04,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,58.9,48.48,,47.12,percent of total billed charges,48.48% of total billed charges,109.35,90,,87.48,percent of total billed charges,90% of total billed charges,48.48,109.35,
AMYLASE SERUM,41000057,CDM,301,RC,82150,HCPCS,outpatient,,,54.5,32.70,,32.7,60,,26.16,percent of total billed charges,60% of total billed charges,26.16,48,,20.928,percent of total billed charges,48% of total billed charges,19.65,100,,,fee schedule,100% of bcbs custom fee schedule,19.65,100,,,fee schedule,100% of bcbs custom fee schedule,21.81,111,,,fee schedule,111% of bcbs custom fee schedule,27.25,50,,21.8,percent of total billed charges,50% of total billed charges,38.15,70,,30.52,percent of total billed charges,70% of total billed charges,26.42,48.48,,21.136,percent of total billed charges,48.48% of total billed charges,6.54,101,,,fee schedule,101% of cms custom fee schedule,26.42,48.48,,21.136,percent of total billed charges,48.48% of total billed charges,38.15,70,,30.52,percent of total billed charges,70% of total billed charges,38.15,70,,30.52,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,26.42,48.48,,21.136,percent of total billed charges,48.48% of total billed charges,49.05,90,,39.24,percent of total billed charges,90% of total billed charges,26.42,90,
"PROSTATE SPECIFIC ANTIGEN, SCREENING",41000482,CDM,300,RC,G0103,HCPCS,outpatient,,,125.5,75.30,,75.3,60,,60.24,percent of total billed charges,60% of total billed charges,60.24,48,,48.192,percent of total billed charges,48% of total billed charges,55.71,100,,,fee schedule,100% of bcbs custom fee schedule,55.71,100,,,fee schedule,100% of bcbs custom fee schedule,61.84,111,,,fee schedule,111% of bcbs custom fee schedule,62.75,50,,50.2,percent of total billed charges,50% of total billed charges,87.85,70,,70.28,percent of total billed charges,70% of total billed charges,60.84,48.48,,48.672,percent of total billed charges,48.48% of total billed charges,19.5,101,,,fee schedule,101% of cms custom fee schedule,60.84,48.48,,48.672,percent of total billed charges,48.48% of total billed charges,87.85,70,,70.28,percent of total billed charges,70% of total billed charges,87.85,70,,70.28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,60.84,48.48,,48.672,percent of total billed charges,48.48% of total billed charges,112.95,90,,90.36,percent of total billed charges,90% of total billed charges,48.48,112.95,
TB ANTIGEN RESP GAMA INTERFERON T-CELL,,,301,RC,86481,HCPCS,outpatient,,,369,221.40,,221.4,60,,177.12,percent of total billed charges,60% of total billed charges,177.12,48,,141.696,percent of total billed charges,48% of total billed charges,159.58,100,,,fee schedule,100% of bcbs custom fee schedule,159.58,100,,,fee schedule,100% of bcbs custom fee schedule,177.13,111,,,fee schedule,111% of bcbs custom fee schedule,184.5,50,,147.6,percent of total billed charges,50% of total billed charges,258.3,70,,206.64,percent of total billed charges,70% of total billed charges,178.89,48.48,,143.112,percent of total billed charges,48.48% of total billed charges,101,101,,,fee schedule,101% of cms custom fee schedule,178.89,48.48,,143.112,percent of total billed charges,48.48% of total billed charges,258.3,70,,206.64,percent of total billed charges,70% of total billed charges,258.3,70,,206.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,178.89,48.48,,143.112,percent of total billed charges,48.48% of total billed charges,332.1,90,,265.68,percent of total billed charges,90% of total billed charges,48.48,332.1,
IRON,41000022,CDM,300,RC,83540,HCPCS,outpatient,,,84,50.40,,9,100,,,fee schedule,100% of aetna fee schedule,40.32,48,,32.256,percent of total billed charges,48% of total billed charges,16.25,100,,,fee schedule,100% of bcbs custom fee schedule,16.25,100,,,fee schedule,100% of bcbs custom fee schedule,18.04,111,,,fee schedule,111% of bcbs custom fee schedule,42,50,,33.6,percent of total billed charges,50% of total billed charges,58.8,70,,47.04,percent of total billed charges,70% of total billed charges,40.72,48.48,,32.576,percent of total billed charges,48.48% of total billed charges,6.53,101,,,fee schedule,101% of cms custom fee schedule,40.72,48.48,,32.576,percent of total billed charges,48.48% of total billed charges,58.8,70,,47.04,percent of total billed charges,70% of total billed charges,58.8,70,,47.04,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,40.72,48.48,,32.576,percent of total billed charges,48.48% of total billed charges,75.6,90,,60.48,percent of total billed charges,90% of total billed charges,40.72,90,
TISSUE HOMOGENIZATION FOR CULTURE,,,300,RC,87176,HCPCS,outpatient,,,56,33.60,,33.6,60,,26.88,percent of total billed charges,60% of total billed charges,26.88,48,,21.504,percent of total billed charges,48% of total billed charges,17.82,100,,,fee schedule,100% of bcbs custom fee schedule,17.82,100,,,fee schedule,100% of bcbs custom fee schedule,19.78,111,,,fee schedule,111% of bcbs custom fee schedule,28,50,,22.4,percent of total billed charges,50% of total billed charges,39.2,70,,31.36,percent of total billed charges,70% of total billed charges,27.15,48.48,,21.72,percent of total billed charges,48.48% of total billed charges,5.94,101,,,fee schedule,101% of cms custom fee schedule,27.15,48.48,,21.72,percent of total billed charges,48.48% of total billed charges,39.2,70,,31.36,percent of total billed charges,70% of total billed charges,39.2,70,,31.36,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,27.15,48.48,,21.72,percent of total billed charges,48.48% of total billed charges,50.4,90,,40.32,percent of total billed charges,90% of total billed charges,27.15,90,
IRON BINDING CAPACITY,41000023,CDM,300,RC,83550,HCPCS,outpatient,,,97,58.20,,58.2,60,,46.56,percent of total billed charges,60% of total billed charges,46.56,48,,37.248,percent of total billed charges,48% of total billed charges,26.46,100,,,fee schedule,100% of bcbs custom fee schedule,26.46,100,,,fee schedule,100% of bcbs custom fee schedule,29.37,111,,,fee schedule,111% of bcbs custom fee schedule,48.5,50,,38.8,percent of total billed charges,50% of total billed charges,67.9,70,,54.32,percent of total billed charges,70% of total billed charges,47.03,48.48,,37.624,percent of total billed charges,48.48% of total billed charges,8.83,101,,,fee schedule,101% of cms custom fee schedule,47.03,48.48,,37.624,percent of total billed charges,48.48% of total billed charges,67.9,70,,54.32,percent of total billed charges,70% of total billed charges,67.9,70,,54.32,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,47.03,48.48,,37.624,percent of total billed charges,48.48% of total billed charges,87.3,90,,69.84,percent of total billed charges,90% of total billed charges,47.03,90,
BLOOD GASES,41000600,CDM,301,RC,82803,HCPCS,outpatient,,,103,61.80,,61.8,60,,49.44,percent of total billed charges,60% of total billed charges,49.44,48,,39.552,percent of total billed charges,48% of total billed charges,15.77,100,,,fee schedule,100% of bcbs custom fee schedule,15.77,100,,,fee schedule,100% of bcbs custom fee schedule,17.5,111,,,fee schedule,111% of bcbs custom fee schedule,51.5,50,,41.2,percent of total billed charges,50% of total billed charges,72.1,70,,57.68,percent of total billed charges,70% of total billed charges,49.93,48.48,,39.944,percent of total billed charges,48.48% of total billed charges,26.33,101,,,fee schedule,101% of cms custom fee schedule,49.93,48.48,,39.944,percent of total billed charges,48.48% of total billed charges,72.1,70,,57.68,percent of total billed charges,70% of total billed charges,72.1,70,,57.68,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,49.93,48.48,,39.944,percent of total billed charges,48.48% of total billed charges,92.7,90,,74.16,percent of total billed charges,90% of total billed charges,48.48,92.7,
BLOOD GAS PH ONLY,41000035,CDM,301,RC,82800,HCPCS,outpatient,,,68,40.80,,40.8,60,,32.64,percent of total billed charges,60% of total billed charges,32.64,48,,26.112,percent of total billed charges,48% of total billed charges,25.65,100,,,fee schedule,100% of bcbs custom fee schedule,25.65,100,,,fee schedule,100% of bcbs custom fee schedule,28.47,111,,,fee schedule,111% of bcbs custom fee schedule,34,50,,27.2,percent of total billed charges,50% of total billed charges,47.6,70,,38.08,percent of total billed charges,70% of total billed charges,32.97,48.48,,26.376,percent of total billed charges,48.48% of total billed charges,11.11,101,,,fee schedule,101% of cms custom fee schedule,32.97,48.48,,26.376,percent of total billed charges,48.48% of total billed charges,47.6,70,,38.08,percent of total billed charges,70% of total billed charges,47.6,70,,38.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,32.97,48.48,,26.376,percent of total billed charges,48.48% of total billed charges,61.2,90,,48.96,percent of total billed charges,90% of total billed charges,32.97,90,
IGG SUBCLASSES 1 2 3 or 4,41000802,CDM,300,RC,82787,HCPCS,outpatient,,,137.5,82.50,,82.5,60,,66,percent of total billed charges,60% of total billed charges,66,48,,52.8,percent of total billed charges,48% of total billed charges,14.68,100,,,fee schedule,100% of bcbs custom fee schedule,14.68,100,,,fee schedule,100% of bcbs custom fee schedule,16.29,111,,,fee schedule,111% of bcbs custom fee schedule,68.75,50,,55,percent of total billed charges,50% of total billed charges,96.25,70,,77,percent of total billed charges,70% of total billed charges,66.66,48.48,,53.328,percent of total billed charges,48.48% of total billed charges,8.1,101,,,fee schedule,101% of cms custom fee schedule,66.66,48.48,,53.328,percent of total billed charges,48.48% of total billed charges,96.25,70,,77,percent of total billed charges,70% of total billed charges,96.25,70,,77,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,66.66,48.48,,53.328,percent of total billed charges,48.48% of total billed charges,123.75,90,,99,percent of total billed charges,90% of total billed charges,48.48,123.75,
ZINC LEVEL,41009151,CDM,300,RC,84630,HCPCS,outpatient,,,108.75,65.25,,65.25,60,,52.2,percent of total billed charges,60% of total billed charges,52.2,48,,41.76,percent of total billed charges,48% of total billed charges,34.49,100,,,fee schedule,100% of bcbs custom fee schedule,34.49,100,,,fee schedule,100% of bcbs custom fee schedule,38.28,111,,,fee schedule,111% of bcbs custom fee schedule,54.38,50,,43.504,percent of total billed charges,50% of total billed charges,76.13,70,,60.904,percent of total billed charges,70% of total billed charges,52.72,48.48,,42.176,percent of total billed charges,48.48% of total billed charges,11.5,101,,,fee schedule,101% of cms custom fee schedule,52.72,48.48,,42.176,percent of total billed charges,48.48% of total billed charges,76.13,70,,60.904,percent of total billed charges,70% of total billed charges,76.13,70,,60.904,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,52.72,48.48,,42.176,percent of total billed charges,48.48% of total billed charges,97.88,90,,78.304,percent of total billed charges,90% of total billed charges,48.48,97.88,
VMA,41009018,CDM,300,RC,84585,HCPCS,outpatient,,,127.5,76.50,91,76.5,60,,61.2,percent of total billed charges,60% of total billed charges,61.2,48,,48.96,percent of total billed charges,48% of total billed charges,46.96,100,,,fee schedule,100% of bcbs custom fee schedule,46.96,100,,,fee schedule,100% of bcbs custom fee schedule,52.13,111,,,fee schedule,111% of bcbs custom fee schedule,63.75,50,,51,percent of total billed charges,50% of total billed charges,89.25,70,,71.4,percent of total billed charges,70% of total billed charges,61.81,48.48,,49.448,percent of total billed charges,48.48% of total billed charges,15.66,101,,,fee schedule,101% of cms custom fee schedule,61.81,48.48,,49.448,percent of total billed charges,48.48% of total billed charges,89.25,70,,71.4,percent of total billed charges,70% of total billed charges,89.25,70,,71.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,61.81,48.48,,49.448,percent of total billed charges,48.48% of total billed charges,114.75,90,,91.8,percent of total billed charges,90% of total billed charges,48.48,114.75,
"TESTOSTERONE, TOTAL",41009015,CDM,300,RC,84403,HCPCS,outpatient,,,175,105.00,,105,60,,84,percent of total billed charges,60% of total billed charges,84,48,,67.2,percent of total billed charges,48% of total billed charges,78.22,100,,,fee schedule,100% of bcbs custom fee schedule,78.22,100,,,fee schedule,100% of bcbs custom fee schedule,86.82,111,,,fee schedule,111% of bcbs custom fee schedule,87.5,50,,70,percent of total billed charges,50% of total billed charges,122.5,70,,98,percent of total billed charges,70% of total billed charges,84.84,48.48,,67.872,percent of total billed charges,48.48% of total billed charges,26.07,101,,,fee schedule,101% of cms custom fee schedule,84.84,48.48,,67.872,percent of total billed charges,48.48% of total billed charges,122.5,70,,98,percent of total billed charges,70% of total billed charges,122.5,70,,98,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,84.84,48.48,,67.872,percent of total billed charges,48.48% of total billed charges,157.5,90,,126,percent of total billed charges,90% of total billed charges,48.48,157.5,
UREA NITROGEN,41000004,CDM,301,RC,84520,HCPCS,outpatient,,,68.5,41.10,,41.1,60,,32.88,percent of total billed charges,60% of total billed charges,32.88,48,,26.304,percent of total billed charges,48% of total billed charges,11.94,100,,,fee schedule,100% of bcbs custom fee schedule,11.94,100,,,fee schedule,100% of bcbs custom fee schedule,13.25,111,,,fee schedule,111% of bcbs custom fee schedule,34.25,50,,27.4,percent of total billed charges,50% of total billed charges,47.95,70,,38.36,percent of total billed charges,70% of total billed charges,33.21,48.48,,26.568,percent of total billed charges,48.48% of total billed charges,3.99,101,,,fee schedule,101% of cms custom fee schedule,33.21,48.48,,26.568,percent of total billed charges,48.48% of total billed charges,47.95,70,,38.36,percent of total billed charges,70% of total billed charges,47.95,70,,38.36,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,33.21,48.48,,26.568,percent of total billed charges,48.48% of total billed charges,61.65,90,,49.32,percent of total billed charges,90% of total billed charges,33.21,90,
"TESTOSTERONE, FREE",41000388,CDM,300,RC,84402,HCPCS,outpatient,,,230,138.00,,138,60,,110.4,percent of total billed charges,60% of total billed charges,110.4,48,,88.32,percent of total billed charges,48% of total billed charges,77.11,100,,,fee schedule,100% of bcbs custom fee schedule,77.11,100,,,fee schedule,100% of bcbs custom fee schedule,85.59,111,,,fee schedule,111% of bcbs custom fee schedule,115,50,,92,percent of total billed charges,50% of total billed charges,161,70,,128.8,percent of total billed charges,70% of total billed charges,111.5,48.48,,89.2,percent of total billed charges,48.48% of total billed charges,25.72,101,,,fee schedule,101% of cms custom fee schedule,111.5,48.48,,89.2,percent of total billed charges,48.48% of total billed charges,161,70,,128.8,percent of total billed charges,70% of total billed charges,161,70,,128.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,111.5,48.48,,89.2,percent of total billed charges,48.48% of total billed charges,207,90,,165.6,percent of total billed charges,90% of total billed charges,48.48,207,
CARBON DIOXIDE (C02),41000449,CDM,301,RC,82374,HCPCS,outpatient,,,29.5,17.70,,17.7,60,,14.16,percent of total billed charges,60% of total billed charges,14.16,48,,11.328,percent of total billed charges,48% of total billed charges,14.81,100,,,fee schedule,100% of bcbs custom fee schedule,14.81,100,,,fee schedule,100% of bcbs custom fee schedule,16.44,111,,,fee schedule,111% of bcbs custom fee schedule,14.75,50,,11.8,percent of total billed charges,50% of total billed charges,20.65,70,,16.52,percent of total billed charges,70% of total billed charges,14.3,48.48,,11.44,percent of total billed charges,48.48% of total billed charges,4.93,101,,,fee schedule,101% of cms custom fee schedule,14.3,48.48,,11.44,percent of total billed charges,48.48% of total billed charges,20.65,70,,16.52,percent of total billed charges,70% of total billed charges,20.65,70,,16.52,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,14.3,48.48,,11.44,percent of total billed charges,48.48% of total billed charges,26.55,90,,21.24,percent of total billed charges,90% of total billed charges,14.3,90,
FIBRINOGEN ACTIVITY,41000064,CDM,300,RC,85384,HCPCS,outpatient,,,73.75,44.25,,44.25,60,,35.4,percent of total billed charges,60% of total billed charges,35.4,48,,28.32,percent of total billed charges,48% of total billed charges,25.73,100,,,fee schedule,100% of bcbs custom fee schedule,25.73,100,,,fee schedule,100% of bcbs custom fee schedule,28.56,111,,,fee schedule,111% of bcbs custom fee schedule,36.88,50,,29.504,percent of total billed charges,50% of total billed charges,51.63,70,,41.304,percent of total billed charges,70% of total billed charges,35.75,48.48,,28.6,percent of total billed charges,48.48% of total billed charges,9.82,101,,,fee schedule,101% of cms custom fee schedule,35.75,48.48,,28.6,percent of total billed charges,48.48% of total billed charges,51.63,70,,41.304,percent of total billed charges,70% of total billed charges,51.63,70,,41.304,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,35.75,48.48,,28.6,percent of total billed charges,48.48% of total billed charges,66.38,90,,53.104,percent of total billed charges,90% of total billed charges,35.75,90,
CALCIUM TOTAL,41000005,CDM,301,RC,82310,HCPCS,outpatient,,,54.5,32.70,,32.7,60,,26.16,percent of total billed charges,60% of total billed charges,26.16,48,,20.928,percent of total billed charges,48% of total billed charges,15.61,100,,,fee schedule,100% of bcbs custom fee schedule,15.61,100,,,fee schedule,100% of bcbs custom fee schedule,17.33,111,,,fee schedule,111% of bcbs custom fee schedule,27.25,50,,21.8,percent of total billed charges,50% of total billed charges,38.15,70,,30.52,percent of total billed charges,70% of total billed charges,26.42,48.48,,21.136,percent of total billed charges,48.48% of total billed charges,5.21,101,,,fee schedule,101% of cms custom fee schedule,26.42,48.48,,21.136,percent of total billed charges,48.48% of total billed charges,38.15,70,,30.52,percent of total billed charges,70% of total billed charges,38.15,70,,30.52,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,26.42,48.48,,21.136,percent of total billed charges,48.48% of total billed charges,49.05,90,,39.24,percent of total billed charges,90% of total billed charges,26.42,90,
TRANSFERRIN,41000180,CDM,300,RC,84466,HCPCS,outpatient,,,115,69.00,,69,60,,55.2,percent of total billed charges,60% of total billed charges,55.2,48,,44.16,percent of total billed charges,48% of total billed charges,38.68,100,,,fee schedule,100% of bcbs custom fee schedule,38.68,100,,,fee schedule,100% of bcbs custom fee schedule,42.93,111,,,fee schedule,111% of bcbs custom fee schedule,57.5,50,,46,percent of total billed charges,50% of total billed charges,80.5,70,,64.4,percent of total billed charges,70% of total billed charges,55.75,48.48,,44.6,percent of total billed charges,48.48% of total billed charges,12.89,101,,,fee schedule,101% of cms custom fee schedule,55.75,48.48,,44.6,percent of total billed charges,48.48% of total billed charges,80.5,70,,64.4,percent of total billed charges,70% of total billed charges,80.5,70,,64.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,55.75,48.48,,44.6,percent of total billed charges,48.48% of total billed charges,103.5,90,,82.8,percent of total billed charges,90% of total billed charges,48.48,103.5,
COURIER FEE,41000029,CDM,300,RC,99001,HCPCS,outpatient,,,46,27.60,,27.6,60,,22.08,percent of total billed charges,60% of total billed charges,22.08,48,,17.664,percent of total billed charges,48% of total billed charges,23,50,,18.4,percent of total billed charges,50% of total billed charges,23,50,,18.4,percent of total billed charges,50% of total billed charges,23,50,,18.4,percent of total billed charges,50% of total billed charges,23,50,,18.4,percent of total billed charges,50% of total billed charges,32.2,70,,25.76,percent of total billed charges,70% of total billed charges,22.3,48.48,,17.84,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,22.3,48.48,,17.84,percent of total billed charges,48.48% of total billed charges,32.2,70,,25.76,percent of total billed charges,70% of total billed charges,32.2,70,,25.76,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,22.3,48.48,,17.84,percent of total billed charges,48.48% of total billed charges,41.4,90,,33.12,percent of total billed charges,90% of total billed charges,22.3,90,
VANCOMYCIN LEVEL,41000441,CDM,300,RC,80202,HCPCS,outpatient,,,173.75,104.25,,104.25,60,,83.4,percent of total billed charges,60% of total billed charges,83.4,48,,66.72,percent of total billed charges,48% of total billed charges,41.04,100,,,fee schedule,100% of bcbs custom fee schedule,41.04,100,,,fee schedule,100% of bcbs custom fee schedule,45.55,111,,,fee schedule,111% of bcbs custom fee schedule,86.88,50,,69.504,percent of total billed charges,50% of total billed charges,121.63,70,,97.304,percent of total billed charges,70% of total billed charges,84.23,48.48,,67.384,percent of total billed charges,48.48% of total billed charges,13.68,101,,,fee schedule,101% of cms custom fee schedule,84.23,48.48,,67.384,percent of total billed charges,48.48% of total billed charges,121.63,70,,97.304,percent of total billed charges,70% of total billed charges,121.63,70,,97.304,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,84.23,48.48,,67.384,percent of total billed charges,48.48% of total billed charges,156.38,90,,125.104,percent of total billed charges,90% of total billed charges,48.48,156.38,
LUTEINIZING HORMONE,41001010,CDM,300,RC,83002,HCPCS,outpatient,,,160,96.00,,96,60,,76.8,percent of total billed charges,60% of total billed charges,76.8,48,,61.44,percent of total billed charges,48% of total billed charges,56.11,100,,,fee schedule,100% of bcbs custom fee schedule,56.11,100,,,fee schedule,100% of bcbs custom fee schedule,62.28,111,,,fee schedule,111% of bcbs custom fee schedule,80,50,,64,percent of total billed charges,50% of total billed charges,112,70,,89.6,percent of total billed charges,70% of total billed charges,77.57,48.48,,62.056,percent of total billed charges,48.48% of total billed charges,18.71,101,,,fee schedule,101% of cms custom fee schedule,77.57,48.48,,62.056,percent of total billed charges,48.48% of total billed charges,112,70,,89.6,percent of total billed charges,70% of total billed charges,112,70,,89.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,77.57,48.48,,62.056,percent of total billed charges,48.48% of total billed charges,144,90,,115.2,percent of total billed charges,90% of total billed charges,48.48,144,
"OSMOLALITY, URINE",41001012,CDM,300,RC,83935,HCPCS,outpatient,,,173.75,104.25,,104.25,60,,83.4,percent of total billed charges,60% of total billed charges,83.4,48,,66.72,percent of total billed charges,48% of total billed charges,20.64,100,,,fee schedule,100% of bcbs custom fee schedule,20.64,100,,,fee schedule,100% of bcbs custom fee schedule,22.91,111,,,fee schedule,111% of bcbs custom fee schedule,86.88,50,,69.504,percent of total billed charges,50% of total billed charges,121.63,70,,97.304,percent of total billed charges,70% of total billed charges,84.23,48.48,,67.384,percent of total billed charges,48.48% of total billed charges,6.89,101,,,fee schedule,101% of cms custom fee schedule,84.23,48.48,,67.384,percent of total billed charges,48.48% of total billed charges,121.63,70,,97.304,percent of total billed charges,70% of total billed charges,121.63,70,,97.304,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,84.23,48.48,,67.384,percent of total billed charges,48.48% of total billed charges,156.38,90,,125.104,percent of total billed charges,90% of total billed charges,48.48,156.38,
CBC COMPLETE AUTOM  W PLT,41000191,CDM,305,RC,85027,HCPCS,outpatient,,,53.75,32.25,,32.25,60,,25.8,percent of total billed charges,60% of total billed charges,25.8,48,,20.64,percent of total billed charges,48% of total billed charges,19.6,100,,,fee schedule,100% of bcbs custom fee schedule,19.6,100,,,fee schedule,100% of bcbs custom fee schedule,21.76,111,,,fee schedule,111% of bcbs custom fee schedule,26.88,50,,21.504,percent of total billed charges,50% of total billed charges,37.63,70,,30.104,percent of total billed charges,70% of total billed charges,26.06,48.48,,20.848,percent of total billed charges,48.48% of total billed charges,6.53,101,,,fee schedule,101% of cms custom fee schedule,26.06,48.48,,20.848,percent of total billed charges,48.48% of total billed charges,37.63,70,,30.104,percent of total billed charges,70% of total billed charges,37.63,70,,30.104,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,26.06,48.48,,20.848,percent of total billed charges,48.48% of total billed charges,48.38,90,,38.704,percent of total billed charges,90% of total billed charges,26.06,90,
CBC W PLT W AUTOM DF,41000100,CDM,305,RC,85025,HCPCS,outpatient,,,75,45.00,,45,60,,36,percent of total billed charges,60% of total billed charges,36,48,,28.8,percent of total billed charges,48% of total billed charges,23.54,100,,,fee schedule,100% of bcbs custom fee schedule,23.54,100,,,fee schedule,100% of bcbs custom fee schedule,26.13,111,,,fee schedule,111% of bcbs custom fee schedule,37.5,50,,30,percent of total billed charges,50% of total billed charges,52.5,70,,42,percent of total billed charges,70% of total billed charges,36.36,48.48,,29.088,percent of total billed charges,48.48% of total billed charges,7.85,101,,,fee schedule,101% of cms custom fee schedule,36.36,48.48,,29.088,percent of total billed charges,48.48% of total billed charges,52.5,70,,42,percent of total billed charges,70% of total billed charges,52.5,70,,42,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,36.36,48.48,,29.088,percent of total billed charges,48.48% of total billed charges,67.5,90,,54,percent of total billed charges,90% of total billed charges,36.36,90,
CELL COUNT BODY FLUIDS,41000324,CDM,301,RC,89050,HCPCS,outpatient,,,142.5,85.50,,85.5,60,,68.4,percent of total billed charges,60% of total billed charges,68.4,48,,54.72,percent of total billed charges,48% of total billed charges,14.34,100,,,fee schedule,100% of bcbs custom fee schedule,14.34,100,,,fee schedule,100% of bcbs custom fee schedule,15.92,111,,,fee schedule,111% of bcbs custom fee schedule,71.25,50,,57,percent of total billed charges,50% of total billed charges,99.75,70,,79.8,percent of total billed charges,70% of total billed charges,69.08,48.48,,55.264,percent of total billed charges,48.48% of total billed charges,4.77,101,,,fee schedule,101% of cms custom fee schedule,69.08,48.48,,55.264,percent of total billed charges,48.48% of total billed charges,99.75,70,,79.8,percent of total billed charges,70% of total billed charges,99.75,70,,79.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,69.08,48.48,,55.264,percent of total billed charges,48.48% of total billed charges,128.25,90,,102.6,percent of total billed charges,90% of total billed charges,48.48,128.25,
"THYROGLOBULIN, ANTIBODY",41000419,CDM,300,RC,86800,HCPCS,outpatient,,,122.5,73.50,,73.5,60,,58.8,percent of total billed charges,60% of total billed charges,58.8,48,,47.04,percent of total billed charges,48% of total billed charges,48.17,100,,,fee schedule,100% of bcbs custom fee schedule,48.17,100,,,fee schedule,100% of bcbs custom fee schedule,53.47,111,,,fee schedule,111% of bcbs custom fee schedule,61.25,50,,49,percent of total billed charges,50% of total billed charges,85.75,70,,68.6,percent of total billed charges,70% of total billed charges,59.39,48.48,,47.512,percent of total billed charges,48.48% of total billed charges,16.07,101,,,fee schedule,101% of cms custom fee schedule,59.39,48.48,,47.512,percent of total billed charges,48.48% of total billed charges,85.75,70,,68.6,percent of total billed charges,70% of total billed charges,85.75,70,,68.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,59.39,48.48,,47.512,percent of total billed charges,48.48% of total billed charges,110.25,90,,88.2,percent of total billed charges,90% of total billed charges,48.48,110.25,
HEPATITIS B CORE ANTIBODY IgM,41000766,CDM,300,RC,86705,HCPCS,outpatient,,,65,39.00,,39,60,,31.2,percent of total billed charges,60% of total billed charges,31.2,48,,24.96,percent of total billed charges,48% of total billed charges,35.63,100,,,fee schedule,100% of bcbs custom fee schedule,35.63,100,,,fee schedule,100% of bcbs custom fee schedule,39.55,111,,,fee schedule,111% of bcbs custom fee schedule,32.5,50,,26,percent of total billed charges,50% of total billed charges,45.5,70,,36.4,percent of total billed charges,70% of total billed charges,31.51,48.48,,25.208,percent of total billed charges,48.48% of total billed charges,11.89,101,,,fee schedule,101% of cms custom fee schedule,31.51,48.48,,25.208,percent of total billed charges,48.48% of total billed charges,45.5,70,,36.4,percent of total billed charges,70% of total billed charges,45.5,70,,36.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,31.51,48.48,,25.208,percent of total billed charges,48.48% of total billed charges,58.5,90,,46.8,percent of total billed charges,90% of total billed charges,31.51,90,
THYROGLOBULIN,41009082,CDM,300,RC,84432,HCPCS,outpatient,,,183.75,110.25,,110.25,60,,88.2,percent of total billed charges,60% of total billed charges,88.2,48,,70.56,percent of total billed charges,48% of total billed charges,48.64,100,,,fee schedule,100% of bcbs custom fee schedule,48.64,100,,,fee schedule,100% of bcbs custom fee schedule,53.99,111,,,fee schedule,111% of bcbs custom fee schedule,91.88,50,,73.504,percent of total billed charges,50% of total billed charges,128.63,70,,102.904,percent of total billed charges,70% of total billed charges,89.08,48.48,,71.264,percent of total billed charges,48.48% of total billed charges,16.22,101,,,fee schedule,101% of cms custom fee schedule,89.08,48.48,,71.264,percent of total billed charges,48.48% of total billed charges,128.63,70,,102.904,percent of total billed charges,70% of total billed charges,128.63,70,,102.904,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,89.08,48.48,,71.264,percent of total billed charges,48.48% of total billed charges,165.38,90,,132.304,percent of total billed charges,90% of total billed charges,48.48,165.38,
CHOLESTROL BLD/SERUM TOT,41000065,CDM,301,RC,82465,HCPCS,outpatient,,,78,46.80,,46.8,60,,37.44,percent of total billed charges,60% of total billed charges,37.44,48,,29.952,percent of total billed charges,48% of total billed charges,13.19,100,,,fee schedule,100% of bcbs custom fee schedule,13.19,100,,,fee schedule,100% of bcbs custom fee schedule,14.64,111,,,fee schedule,111% of bcbs custom fee schedule,39,50,,31.2,percent of total billed charges,50% of total billed charges,54.6,70,,43.68,percent of total billed charges,70% of total billed charges,37.81,48.48,,30.248,percent of total billed charges,48.48% of total billed charges,4.39,101,,,fee schedule,101% of cms custom fee schedule,37.81,48.48,,30.248,percent of total billed charges,48.48% of total billed charges,54.6,70,,43.68,percent of total billed charges,70% of total billed charges,54.6,70,,43.68,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,37.81,48.48,,30.248,percent of total billed charges,48.48% of total billed charges,70.2,90,,56.16,percent of total billed charges,90% of total billed charges,37.81,90,
T3 or T4 UPTAKE or THBR,41000901,CDM,300,RC,84479,HCPCS,outpatient,,,82,49.20,,49.2,60,,39.36,percent of total billed charges,60% of total billed charges,39.36,48,,31.488,percent of total billed charges,48% of total billed charges,14.09,100,,,fee schedule,100% of bcbs custom fee schedule,14.09,100,,,fee schedule,100% of bcbs custom fee schedule,15.64,111,,,fee schedule,111% of bcbs custom fee schedule,41,50,,32.8,percent of total billed charges,50% of total billed charges,57.4,70,,45.92,percent of total billed charges,70% of total billed charges,39.75,48.48,,31.8,percent of total billed charges,48.48% of total billed charges,6.53,101,,,fee schedule,101% of cms custom fee schedule,39.75,48.48,,31.8,percent of total billed charges,48.48% of total billed charges,57.4,70,,45.92,percent of total billed charges,70% of total billed charges,57.4,70,,45.92,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,39.75,48.48,,31.8,percent of total billed charges,48.48% of total billed charges,73.8,90,,59.04,percent of total billed charges,90% of total billed charges,39.75,90,
CHLORIDE,41000026,CDM,301,RC,82435,HCPCS,outpatient,,,35,21.00,,21,60,,16.8,percent of total billed charges,60% of total billed charges,16.8,48,,13.44,percent of total billed charges,48% of total billed charges,13.91,100,,,fee schedule,100% of bcbs custom fee schedule,13.91,100,,,fee schedule,100% of bcbs custom fee schedule,15.44,111,,,fee schedule,111% of bcbs custom fee schedule,17.5,50,,14,percent of total billed charges,50% of total billed charges,24.5,70,,19.6,percent of total billed charges,70% of total billed charges,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,4.65,101,,,fee schedule,101% of cms custom fee schedule,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,24.5,70,,19.6,percent of total billed charges,70% of total billed charges,24.5,70,,19.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,31.5,90,,25.2,percent of total billed charges,90% of total billed charges,16.97,90,
T3 TOTAL,41000084,CDM,300,RC,84480,HCPCS,outpatient,,,116,69.60,,69.6,60,,55.68,percent of total billed charges,60% of total billed charges,55.68,48,,44.544,percent of total billed charges,48% of total billed charges,19.45,100,,,fee schedule,100% of bcbs custom fee schedule,19.45,100,,,fee schedule,100% of bcbs custom fee schedule,21.59,111,,,fee schedule,111% of bcbs custom fee schedule,58,50,,46.4,percent of total billed charges,50% of total billed charges,81.2,70,,64.96,percent of total billed charges,70% of total billed charges,56.24,48.48,,44.992,percent of total billed charges,48.48% of total billed charges,14.32,101,,,fee schedule,101% of cms custom fee schedule,56.24,48.48,,44.992,percent of total billed charges,48.48% of total billed charges,81.2,70,,64.96,percent of total billed charges,70% of total billed charges,81.2,70,,64.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,56.24,48.48,,44.992,percent of total billed charges,48.48% of total billed charges,104.4,90,,83.52,percent of total billed charges,90% of total billed charges,48.48,104.4,
ANTIDIURETIC HORMONE/ VASOPRESSIN LEVEL,41000393,CDM,300,RC,84588,HCPCS,outpatient,,,196,117.60,,117.6,60,,94.08,percent of total billed charges,60% of total billed charges,94.08,48,,75.264,percent of total billed charges,48% of total billed charges,102.82,100,,,fee schedule,100% of bcbs custom fee schedule,102.82,100,,,fee schedule,100% of bcbs custom fee schedule,114.13,111,,,fee schedule,111% of bcbs custom fee schedule,98,50,,78.4,percent of total billed charges,50% of total billed charges,137.2,70,,109.76,percent of total billed charges,70% of total billed charges,95.02,48.48,,76.016,percent of total billed charges,48.48% of total billed charges,34.28,101,,,fee schedule,101% of cms custom fee schedule,95.02,48.48,,76.016,percent of total billed charges,48.48% of total billed charges,137.2,70,,109.76,percent of total billed charges,70% of total billed charges,137.2,70,,109.76,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,95.02,48.48,,76.016,percent of total billed charges,48.48% of total billed charges,176.4,90,,141.12,percent of total billed charges,90% of total billed charges,48.48,176.4,
PARATHYROID HORMONE,41000016,CDM,300,RC,83970,HCPCS,outpatient,,,233,139.80,,139.8,60,,111.84,percent of total billed charges,60% of total billed charges,111.84,48,,89.472,percent of total billed charges,48% of total billed charges,125.01,100,,,fee schedule,100% of bcbs custom fee schedule,125.01,100,,,fee schedule,100% of bcbs custom fee schedule,138.76,111,,,fee schedule,111% of bcbs custom fee schedule,116.5,50,,93.2,percent of total billed charges,50% of total billed charges,163.1,70,,130.48,percent of total billed charges,70% of total billed charges,112.96,48.48,,90.368,percent of total billed charges,48.48% of total billed charges,41.69,101,,,fee schedule,101% of cms custom fee schedule,112.96,48.48,,90.368,percent of total billed charges,48.48% of total billed charges,163.1,70,,130.48,percent of total billed charges,70% of total billed charges,163.1,70,,130.48,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,112.96,48.48,,90.368,percent of total billed charges,48.48% of total billed charges,209.7,90,,167.76,percent of total billed charges,90% of total billed charges,48.48,209.7,
"CREATINE KINASE,CPK;TOTAL",41000007,CDM,301,RC,82550,HCPCS,outpatient,,,50,30.00,,30,60,,24,percent of total billed charges,60% of total billed charges,24,48,,19.2,percent of total billed charges,48% of total billed charges,19.72,100,,,fee schedule,100% of bcbs custom fee schedule,19.72,100,,,fee schedule,100% of bcbs custom fee schedule,21.89,111,,,fee schedule,111% of bcbs custom fee schedule,25,50,,20,percent of total billed charges,50% of total billed charges,35,70,,28,percent of total billed charges,70% of total billed charges,24.24,48.48,,19.392,percent of total billed charges,48.48% of total billed charges,6.58,101,,,fee schedule,101% of cms custom fee schedule,24.24,48.48,,19.392,percent of total billed charges,48.48% of total billed charges,35,70,,28,percent of total billed charges,70% of total billed charges,35,70,,28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,24.24,48.48,,19.392,percent of total billed charges,48.48% of total billed charges,45,90,,36,percent of total billed charges,90% of total billed charges,24.24,90,
RENIN ACTIVITY,41000452,CDM,300,RC,84244,HCPCS,outpatient,,,310,186.00,,186,60,,148.8,percent of total billed charges,60% of total billed charges,148.8,48,,119.04,percent of total billed charges,48% of total billed charges,66.62,100,,,fee schedule,100% of bcbs custom fee schedule,66.62,100,,,fee schedule,100% of bcbs custom fee schedule,73.95,111,,,fee schedule,111% of bcbs custom fee schedule,155,50,,124,percent of total billed charges,50% of total billed charges,217,70,,173.6,percent of total billed charges,70% of total billed charges,150.29,48.48,,120.232,percent of total billed charges,48.48% of total billed charges,22.21,101,,,fee schedule,101% of cms custom fee schedule,150.29,48.48,,120.232,percent of total billed charges,48.48% of total billed charges,217,70,,173.6,percent of total billed charges,70% of total billed charges,217,70,,173.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,150.29,48.48,,120.232,percent of total billed charges,48.48% of total billed charges,279,90,,223.2,percent of total billed charges,90% of total billed charges,48.48,279,
CKMB (MB FRACTION),41000224,CDM,301,RC,82553,HCPCS,outpatient,,,140,84.00,,84,60,,67.2,percent of total billed charges,60% of total billed charges,67.2,48,,53.76,percent of total billed charges,48% of total billed charges,34.97,100,,,fee schedule,100% of bcbs custom fee schedule,34.97,100,,,fee schedule,100% of bcbs custom fee schedule,38.82,111,,,fee schedule,111% of bcbs custom fee schedule,70,50,,56,percent of total billed charges,50% of total billed charges,98,70,,78.4,percent of total billed charges,70% of total billed charges,67.87,48.48,,54.296,percent of total billed charges,48.48% of total billed charges,11.67,101,,,fee schedule,101% of cms custom fee schedule,67.87,48.48,,54.296,percent of total billed charges,48.48% of total billed charges,98,70,,78.4,percent of total billed charges,70% of total billed charges,98,70,,78.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,67.87,48.48,,54.296,percent of total billed charges,48.48% of total billed charges,126,90,,100.8,percent of total billed charges,90% of total billed charges,48.48,126,
"CREATININE, BLOOD",41000008,CDM,301,RC,82565,HCPCS,outpatient,,,33,19.80,,19.8,60,,15.84,percent of total billed charges,60% of total billed charges,15.84,48,,12.672,percent of total billed charges,48% of total billed charges,15.52,100,,,fee schedule,100% of bcbs custom fee schedule,15.52,100,,,fee schedule,100% of bcbs custom fee schedule,17.23,111,,,fee schedule,111% of bcbs custom fee schedule,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,23.1,70,,18.48,percent of total billed charges,70% of total billed charges,16,48.48,,12.8,percent of total billed charges,48.48% of total billed charges,5.17,101,,,fee schedule,101% of cms custom fee schedule,16,48.48,,12.8,percent of total billed charges,48.48% of total billed charges,23.1,70,,18.48,percent of total billed charges,70% of total billed charges,23.1,70,,18.48,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,16,48.48,,12.8,percent of total billed charges,48.48% of total billed charges,29.7,90,,23.76,percent of total billed charges,90% of total billed charges,16,90,
"MYOGLOBIN, Urine or Serum",41000151,CDM,300,RC,83874,HCPCS,outpatient,,,111,66.60,,66.6,60,,53.28,percent of total billed charges,60% of total billed charges,53.28,48,,42.624,percent of total billed charges,48% of total billed charges,39.11,100,,,fee schedule,100% of bcbs custom fee schedule,39.11,100,,,fee schedule,100% of bcbs custom fee schedule,43.41,111,,,fee schedule,111% of bcbs custom fee schedule,55.5,50,,44.4,percent of total billed charges,50% of total billed charges,77.7,70,,62.16,percent of total billed charges,70% of total billed charges,53.81,48.48,,43.048,percent of total billed charges,48.48% of total billed charges,13.05,101,,,fee schedule,101% of cms custom fee schedule,53.81,48.48,,43.048,percent of total billed charges,48.48% of total billed charges,77.7,70,,62.16,percent of total billed charges,70% of total billed charges,77.7,70,,62.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,53.81,48.48,,43.048,percent of total billed charges,48.48% of total billed charges,99.9,90,,79.92,percent of total billed charges,90% of total billed charges,48.48,99.9,
"STOOL CULTURE, ADDITIONAL PLATE",,,300,RC,87046,HCPCS,outpatient,,,69.5,41.70,,41.7,60,,33.36,percent of total billed charges,60% of total billed charges,33.36,48,,26.688,percent of total billed charges,48% of total billed charges,28.57,100,,,fee schedule,100% of bcbs custom fee schedule,28.57,100,,,fee schedule,100% of bcbs custom fee schedule,31.71,111,,,fee schedule,111% of bcbs custom fee schedule,34.75,50,,27.8,percent of total billed charges,50% of total billed charges,48.65,70,,38.92,percent of total billed charges,70% of total billed charges,33.69,48.48,,26.952,percent of total billed charges,48.48% of total billed charges,9.53,101,,,fee schedule,101% of cms custom fee schedule,33.69,48.48,,26.952,percent of total billed charges,48.48% of total billed charges,48.65,70,,38.92,percent of total billed charges,70% of total billed charges,48.65,70,,38.92,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,33.69,48.48,,26.952,percent of total billed charges,48.48% of total billed charges,62.55,90,,50.04,percent of total billed charges,90% of total billed charges,33.69,90,
GAMMA GLUTAMYLTRANSFERASE,41000463,CDM,300,RC,82977,HCPCS,outpatient,,,73.75,44.25,,44.25,60,,35.4,percent of total billed charges,60% of total billed charges,35.4,48,,28.32,percent of total billed charges,48% of total billed charges,21.82,100,,,fee schedule,100% of bcbs custom fee schedule,21.82,100,,,fee schedule,100% of bcbs custom fee schedule,24.22,111,,,fee schedule,111% of bcbs custom fee schedule,36.88,50,,29.504,percent of total billed charges,50% of total billed charges,51.63,70,,41.304,percent of total billed charges,70% of total billed charges,35.75,48.48,,28.6,percent of total billed charges,48.48% of total billed charges,7.27,101,,,fee schedule,101% of cms custom fee schedule,35.75,48.48,,28.6,percent of total billed charges,48.48% of total billed charges,51.63,70,,41.304,percent of total billed charges,70% of total billed charges,51.63,70,,41.304,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,35.75,48.48,,28.6,percent of total billed charges,48.48% of total billed charges,66.38,90,,53.104,percent of total billed charges,90% of total billed charges,35.75,90,
"CULTURE, BLOOD BACTERIA",41000307,CDM,300,RC,87040,HCPCS,outpatient,,,85.5,51.30,91,51.3,60,,41.04,percent of total billed charges,60% of total billed charges,41.04,48,,32.832,percent of total billed charges,48% of total billed charges,31.25,100,,,fee schedule,100% of bcbs custom fee schedule,31.25,100,,,fee schedule,100% of bcbs custom fee schedule,34.69,111,,,fee schedule,111% of bcbs custom fee schedule,42.75,50,,34.2,percent of total billed charges,50% of total billed charges,59.85,70,,47.88,percent of total billed charges,70% of total billed charges,41.45,48.48,,33.16,percent of total billed charges,48.48% of total billed charges,10.42,101,,,fee schedule,101% of cms custom fee schedule,41.45,48.48,,33.16,percent of total billed charges,48.48% of total billed charges,59.85,70,,47.88,percent of total billed charges,70% of total billed charges,59.85,70,,47.88,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,41.45,48.48,,33.16,percent of total billed charges,48.48% of total billed charges,76.95,90,,61.56,percent of total billed charges,90% of total billed charges,41.45,90,
FOLLICLE STIMULATING HORMONE,41000072,CDM,300,RC,83001,HCPCS,outpatient,,,138.5,83.10,,83.1,60,,66.48,percent of total billed charges,60% of total billed charges,66.48,48,,53.184,percent of total billed charges,48% of total billed charges,56.3,100,,,fee schedule,100% of bcbs custom fee schedule,56.3,100,,,fee schedule,100% of bcbs custom fee schedule,62.49,111,,,fee schedule,111% of bcbs custom fee schedule,69.25,50,,55.4,percent of total billed charges,50% of total billed charges,96.95,70,,77.56,percent of total billed charges,70% of total billed charges,67.14,48.48,,53.712,percent of total billed charges,48.48% of total billed charges,18.77,101,,,fee schedule,101% of cms custom fee schedule,67.14,48.48,,53.712,percent of total billed charges,48.48% of total billed charges,96.95,70,,77.56,percent of total billed charges,70% of total billed charges,96.95,70,,77.56,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,67.14,48.48,,53.712,percent of total billed charges,48.48% of total billed charges,124.65,90,,99.72,percent of total billed charges,90% of total billed charges,48.48,124.65,
5-HIAA,41000197,CDM,300,RC,83497,HCPCS,outpatient,,,117.5,70.50,,70.5,60,,56.4,percent of total billed charges,60% of total billed charges,56.4,48,,45.12,percent of total billed charges,48% of total billed charges,39.04,100,,,fee schedule,100% of bcbs custom fee schedule,39.04,100,,,fee schedule,100% of bcbs custom fee schedule,43.33,111,,,fee schedule,111% of bcbs custom fee schedule,58.75,50,,47,percent of total billed charges,50% of total billed charges,82.25,70,,65.8,percent of total billed charges,70% of total billed charges,56.96,48.48,,45.568,percent of total billed charges,48.48% of total billed charges,13.03,101,,,fee schedule,101% of cms custom fee schedule,56.96,48.48,,45.568,percent of total billed charges,48.48% of total billed charges,82.25,70,,65.8,percent of total billed charges,70% of total billed charges,82.25,70,,65.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,56.96,48.48,,45.568,percent of total billed charges,48.48% of total billed charges,105.75,90,,84.6,percent of total billed charges,90% of total billed charges,48.48,105.75,
T4 FREE,41000440,CDM,300,RC,84439,HCPCS,outpatient,,,127.5,76.50,,76.5,60,,61.2,percent of total billed charges,60% of total billed charges,61.2,48,,48.96,percent of total billed charges,48% of total billed charges,27.31,100,,,fee schedule,100% of bcbs custom fee schedule,27.31,100,,,fee schedule,100% of bcbs custom fee schedule,30.31,111,,,fee schedule,111% of bcbs custom fee schedule,63.75,50,,51,percent of total billed charges,50% of total billed charges,89.25,70,,71.4,percent of total billed charges,70% of total billed charges,61.81,48.48,,49.448,percent of total billed charges,48.48% of total billed charges,9.11,101,,,fee schedule,101% of cms custom fee schedule,61.81,48.48,,49.448,percent of total billed charges,48.48% of total billed charges,89.25,70,,71.4,percent of total billed charges,70% of total billed charges,89.25,70,,71.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,61.81,48.48,,49.448,percent of total billed charges,48.48% of total billed charges,114.75,90,,91.8,percent of total billed charges,90% of total billed charges,48.48,114.75,
SARS Coronavirus 2 IgG AB,,,300,RC,86769,HCPCS,outpatient,,,105,63.00,,63,60,,50.4,percent of total billed charges,60% of total billed charges,50.4,48,,40.32,percent of total billed charges,48% of total billed charges,42.13,100,,,fee schedule,100% of bcbs custom fee schedule,42.13,100,,,fee schedule,100% of bcbs custom fee schedule,46.76,111,,,fee schedule,111% of bcbs custom fee schedule,52.5,50,,42,percent of total billed charges,50% of total billed charges,73.5,70,,58.8,percent of total billed charges,70% of total billed charges,50.9,48.48,,40.72,percent of total billed charges,48.48% of total billed charges,42.55,101,,,fee schedule,101% of cms custom fee schedule,50.9,48.48,,40.72,percent of total billed charges,48.48% of total billed charges,73.5,70,,58.8,percent of total billed charges,70% of total billed charges,73.5,70,,58.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,50.9,48.48,,40.72,percent of total billed charges,48.48% of total billed charges,94.5,90,,75.6,percent of total billed charges,90% of total billed charges,48.48,94.5,
T3 FREE,41000483,CDM,300,RC,84481,HCPCS,outpatient,,,237.5,142.50,,142.5,60,,114,percent of total billed charges,60% of total billed charges,114,48,,91.2,percent of total billed charges,48% of total billed charges,29.86,100,,,fee schedule,100% of bcbs custom fee schedule,29.86,100,,,fee schedule,100% of bcbs custom fee schedule,33.14,111,,,fee schedule,111% of bcbs custom fee schedule,118.75,50,,95,percent of total billed charges,50% of total billed charges,166.25,70,,133,percent of total billed charges,70% of total billed charges,115.14,48.48,,92.112,percent of total billed charges,48.48% of total billed charges,17.11,101,,,fee schedule,101% of cms custom fee schedule,115.14,48.48,,92.112,percent of total billed charges,48.48% of total billed charges,166.25,70,,133,percent of total billed charges,70% of total billed charges,166.25,70,,133,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,115.14,48.48,,92.112,percent of total billed charges,48.48% of total billed charges,213.75,90,,171,percent of total billed charges,90% of total billed charges,48.48,213.75,
ESTRADIOL LEVEL,41000792,CDM,300,RC,82670,HCPCS,outpatient,,,206.5,123.90,,123.9,60,,99.12,percent of total billed charges,60% of total billed charges,99.12,48,,79.296,percent of total billed charges,48% of total billed charges,84.64,100,,,fee schedule,100% of bcbs custom fee schedule,84.64,100,,,fee schedule,100% of bcbs custom fee schedule,93.95,111,,,fee schedule,111% of bcbs custom fee schedule,103.25,50,,82.6,percent of total billed charges,50% of total billed charges,144.55,70,,115.64,percent of total billed charges,70% of total billed charges,100.11,48.48,,80.088,percent of total billed charges,48.48% of total billed charges,28.22,101,,,fee schedule,101% of cms custom fee schedule,100.11,48.48,,80.088,percent of total billed charges,48.48% of total billed charges,144.55,70,,115.64,percent of total billed charges,70% of total billed charges,144.55,70,,115.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,100.11,48.48,,80.088,percent of total billed charges,48.48% of total billed charges,185.85,90,,148.68,percent of total billed charges,90% of total billed charges,48.48,185.85,
CRP (C-REATIVE PROTEIN),41000213,CDM,300,RC,86140,HCPCS,outpatient,,,45.5,27.30,,27.3,60,,21.84,percent of total billed charges,60% of total billed charges,21.84,48,,17.472,percent of total billed charges,48% of total billed charges,15.67,100,,,fee schedule,100% of bcbs custom fee schedule,15.67,100,,,fee schedule,100% of bcbs custom fee schedule,17.39,111,,,fee schedule,111% of bcbs custom fee schedule,22.75,50,,18.2,percent of total billed charges,50% of total billed charges,31.85,70,,25.48,percent of total billed charges,70% of total billed charges,22.06,48.48,,17.648,percent of total billed charges,48.48% of total billed charges,5.23,101,,,fee schedule,101% of cms custom fee schedule,22.06,48.48,,17.648,percent of total billed charges,48.48% of total billed charges,31.85,70,,25.48,percent of total billed charges,70% of total billed charges,31.85,70,,25.48,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,22.06,48.48,,17.648,percent of total billed charges,48.48% of total billed charges,40.95,90,,32.76,percent of total billed charges,90% of total billed charges,22.06,90,
COVID-19 testing by private lab,41001236,CDM,300,RC,87635,HCPCS,outpatient,,,140,84.00,,84,60,,67.2,percent of total billed charges,60% of total billed charges,67.2,48,,53.76,percent of total billed charges,48% of total billed charges,77,100,,,fee schedule,100% of bcbs custom fee schedule,77,100,,,fee schedule,100% of bcbs custom fee schedule,85.47,111,,,fee schedule,111% of bcbs custom fee schedule,70,50,,56,percent of total billed charges,50% of total billed charges,98,70,,78.4,percent of total billed charges,70% of total billed charges,67.87,48.48,,54.296,percent of total billed charges,48.48% of total billed charges,51.82,101,,,fee schedule,101% of cms custom fee schedule,67.87,48.48,,54.296,percent of total billed charges,48.48% of total billed charges,98,70,,78.4,percent of total billed charges,70% of total billed charges,98,70,,78.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,67.87,48.48,,54.296,percent of total billed charges,48.48% of total billed charges,126,90,,100.8,percent of total billed charges,90% of total billed charges,48.48,126,
"CORTISOL, TOTAL",41000333,CDM,300,RC,82533,HCPCS,outpatient,,,162.5,97.50,,97.5,60,,78,percent of total billed charges,60% of total billed charges,78,48,,62.4,percent of total billed charges,48% of total billed charges,49.38,100,,,fee schedule,100% of bcbs custom fee schedule,49.38,100,,,fee schedule,100% of bcbs custom fee schedule,54.81,111,,,fee schedule,111% of bcbs custom fee schedule,81.25,50,,65,percent of total billed charges,50% of total billed charges,113.75,70,,91,percent of total billed charges,70% of total billed charges,78.78,48.48,,63.024,percent of total billed charges,48.48% of total billed charges,16.46,101,,,fee schedule,101% of cms custom fee schedule,78.78,48.48,,63.024,percent of total billed charges,48.48% of total billed charges,113.75,70,,91,percent of total billed charges,70% of total billed charges,113.75,70,,91,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,78.78,48.48,,63.024,percent of total billed charges,48.48% of total billed charges,146.25,90,,117,percent of total billed charges,90% of total billed charges,48.48,146.25,
Specimen Collection Coronavirus 2,41001233,CDM,300,RC,C9803,HCPCS,outpatient,,,48,28.80,,28.8,60,,23.04,percent of total billed charges,60% of total billed charges,23.04,48,,18.432,percent of total billed charges,48% of total billed charges,34.5,100,,,fee schedule,100% of bcbs custom fee schedule,34.5,100,,,fee schedule,100% of bcbs custom fee schedule,38.3,111,,,fee schedule,111% of bcbs custom fee schedule,24,50,,19.2,percent of total billed charges,50% of total billed charges,33.6,70,,26.88,percent of total billed charges,70% of total billed charges,23.27,48.48,,18.616,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,23.27,48.48,,18.616,percent of total billed charges,48.48% of total billed charges,33.6,70,,26.88,percent of total billed charges,70% of total billed charges,33.6,70,,26.88,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,23.27,48.48,,18.616,percent of total billed charges,48.48% of total billed charges,43.2,90,,34.56,percent of total billed charges,90% of total billed charges,23.27,90,
"CORTISOL, FREE",,,300,RC,82530,HCPCS,outpatient,,,156.25,93.75,,93.75,60,,75,percent of total billed charges,60% of total billed charges,75,48,,60,percent of total billed charges,48% of total billed charges,50.62,100,,,fee schedule,100% of bcbs custom fee schedule,50.62,100,,,fee schedule,100% of bcbs custom fee schedule,56.19,111,,,fee schedule,111% of bcbs custom fee schedule,78.13,50,,62.504,percent of total billed charges,50% of total billed charges,109.38,70,,87.504,percent of total billed charges,70% of total billed charges,75.75,48.48,,60.6,percent of total billed charges,48.48% of total billed charges,16.88,101,,,fee schedule,101% of cms custom fee schedule,75.75,48.48,,60.6,percent of total billed charges,48.48% of total billed charges,109.38,70,,87.504,percent of total billed charges,70% of total billed charges,109.38,70,,87.504,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,75.75,48.48,,60.6,percent of total billed charges,48.48% of total billed charges,140.63,90,,112.504,percent of total billed charges,90% of total billed charges,48.48,140.63,
ADDITIONAL SENSITIVITY,41000508,CDM,300,RC,87184,HCPCS,outpatient,,,27.5,16.50,91,16.5,60,,13.2,percent of total billed charges,60% of total billed charges,13.2,48,,10.56,percent of total billed charges,48% of total billed charges,20.88,100,,,fee schedule,100% of bcbs custom fee schedule,20.88,100,,,fee schedule,100% of bcbs custom fee schedule,23.18,111,,,fee schedule,111% of bcbs custom fee schedule,13.75,50,,11,percent of total billed charges,50% of total billed charges,19.25,70,,15.4,percent of total billed charges,70% of total billed charges,13.33,48.48,,10.664,percent of total billed charges,48.48% of total billed charges,7.55,101,,,fee schedule,101% of cms custom fee schedule,13.33,48.48,,10.664,percent of total billed charges,48.48% of total billed charges,19.25,70,,15.4,percent of total billed charges,70% of total billed charges,19.25,70,,15.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,13.33,48.48,,10.664,percent of total billed charges,48.48% of total billed charges,24.75,90,,19.8,percent of total billed charges,90% of total billed charges,13.33,90,
CK ISOENZYMES,41000078,CDM,300,RC,82552,HCPCS,outpatient,,,187.5,112.50,,112.5,60,,90,percent of total billed charges,60% of total billed charges,90,48,,72,percent of total billed charges,48% of total billed charges,40.55,100,,,fee schedule,100% of bcbs custom fee schedule,40.55,100,,,fee schedule,100% of bcbs custom fee schedule,45.01,111,,,fee schedule,111% of bcbs custom fee schedule,93.75,50,,75,percent of total billed charges,50% of total billed charges,131.25,70,,105,percent of total billed charges,70% of total billed charges,90.9,48.48,,72.72,percent of total billed charges,48.48% of total billed charges,13.52,101,,,fee schedule,101% of cms custom fee schedule,90.9,48.48,,72.72,percent of total billed charges,48.48% of total billed charges,131.25,70,,105,percent of total billed charges,70% of total billed charges,131.25,70,,105,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,90.9,48.48,,72.72,percent of total billed charges,48.48% of total billed charges,168.75,90,,135,percent of total billed charges,90% of total billed charges,48.48,168.75,
ALDOSTERONE,41009005,CDM,300,RC,82088,HCPCS,outpatient,,,288,172.80,,172.8,60,,138.24,percent of total billed charges,60% of total billed charges,138.24,48,,110.592,percent of total billed charges,48% of total billed charges,123.43,100,,,fee schedule,100% of bcbs custom fee schedule,123.43,100,,,fee schedule,100% of bcbs custom fee schedule,137.01,111,,,fee schedule,111% of bcbs custom fee schedule,144,50,,115.2,percent of total billed charges,50% of total billed charges,201.6,70,,161.28,percent of total billed charges,70% of total billed charges,139.62,48.48,,111.696,percent of total billed charges,48.48% of total billed charges,41.16,101,,,fee schedule,101% of cms custom fee schedule,139.62,48.48,,111.696,percent of total billed charges,48.48% of total billed charges,201.6,70,,161.28,percent of total billed charges,70% of total billed charges,201.6,70,,161.28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,139.62,48.48,,111.696,percent of total billed charges,48.48% of total billed charges,259.2,90,,207.36,percent of total billed charges,90% of total billed charges,48.48,259.2,
CHOLINESTERASE SERUM,41000466,CDM,300,RC,82480,HCPCS,outpatient,,,90,54.00,,54,60,,43.2,percent of total billed charges,60% of total billed charges,43.2,48,,34.56,percent of total billed charges,48% of total billed charges,23.87,100,,,fee schedule,100% of bcbs custom fee schedule,23.87,100,,,fee schedule,100% of bcbs custom fee schedule,26.5,111,,,fee schedule,111% of bcbs custom fee schedule,45,50,,36,percent of total billed charges,50% of total billed charges,63,70,,50.4,percent of total billed charges,70% of total billed charges,43.63,48.48,,34.904,percent of total billed charges,48.48% of total billed charges,7.95,101,,,fee schedule,101% of cms custom fee schedule,43.63,48.48,,34.904,percent of total billed charges,48.48% of total billed charges,63,70,,50.4,percent of total billed charges,70% of total billed charges,63,70,,50.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,43.63,48.48,,34.904,percent of total billed charges,48.48% of total billed charges,81,90,,64.8,percent of total billed charges,90% of total billed charges,43.63,90,
ALDOLASE,41009003,CDM,300,RC,82085,HCPCS,outpatient,,,89.5,53.70,,53.7,60,,42.96,percent of total billed charges,60% of total billed charges,42.96,48,,34.368,percent of total billed charges,48% of total billed charges,29.4,100,,,fee schedule,100% of bcbs custom fee schedule,29.4,100,,,fee schedule,100% of bcbs custom fee schedule,32.63,111,,,fee schedule,111% of bcbs custom fee schedule,44.75,50,,35.8,percent of total billed charges,50% of total billed charges,62.65,70,,50.12,percent of total billed charges,70% of total billed charges,43.39,48.48,,34.712,percent of total billed charges,48.48% of total billed charges,9.81,101,,,fee schedule,101% of cms custom fee schedule,43.39,48.48,,34.712,percent of total billed charges,48.48% of total billed charges,62.65,70,,50.12,percent of total billed charges,70% of total billed charges,62.65,70,,50.12,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,43.39,48.48,,34.712,percent of total billed charges,48.48% of total billed charges,80.55,90,,64.44,percent of total billed charges,90% of total billed charges,43.39,90,
THROAT CULTURE,41000047,CDM,306,RC,87070,HCPCS,outpatient,,,82.5,49.50,,49.5,60,,39.6,percent of total billed charges,60% of total billed charges,39.6,48,,31.68,percent of total billed charges,48% of total billed charges,26.08,100,,,fee schedule,100% of bcbs custom fee schedule,26.08,100,,,fee schedule,100% of bcbs custom fee schedule,28.95,111,,,fee schedule,111% of bcbs custom fee schedule,41.25,50,,33,percent of total billed charges,50% of total billed charges,57.75,70,,46.2,percent of total billed charges,70% of total billed charges,40,48.48,,32,percent of total billed charges,48.48% of total billed charges,8.71,101,,,fee schedule,101% of cms custom fee schedule,40,48.48,,32,percent of total billed charges,48.48% of total billed charges,57.75,70,,46.2,percent of total billed charges,70% of total billed charges,57.75,70,,46.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,40,48.48,,32,percent of total billed charges,48.48% of total billed charges,74.25,90,,59.4,percent of total billed charges,90% of total billed charges,40,90,
GENTAMICIN LEVEL,41009050,CDM,300,RC,80170,HCPCS,outpatient,,,142.5,85.50,91,85.5,60,,68.4,percent of total billed charges,60% of total billed charges,68.4,48,,54.72,percent of total billed charges,48% of total billed charges,35.24,100,,,fee schedule,100% of bcbs custom fee schedule,35.24,100,,,fee schedule,100% of bcbs custom fee schedule,39.12,111,,,fee schedule,111% of bcbs custom fee schedule,71.25,50,,57,percent of total billed charges,50% of total billed charges,99.75,70,,79.8,percent of total billed charges,70% of total billed charges,69.08,48.48,,55.264,percent of total billed charges,48.48% of total billed charges,16.54,101,,,fee schedule,101% of cms custom fee schedule,69.08,48.48,,55.264,percent of total billed charges,48.48% of total billed charges,99.75,70,,79.8,percent of total billed charges,70% of total billed charges,99.75,70,,79.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,69.08,48.48,,55.264,percent of total billed charges,48.48% of total billed charges,128.25,90,,102.6,percent of total billed charges,90% of total billed charges,48.48,128.25,
Lacosamide Level,,,300,RC,80235,HCPCS,outpatient,,,235,141.00,,141,60,,112.8,percent of total billed charges,60% of total billed charges,112.8,48,,90.24,percent of total billed charges,48% of total billed charges,49.6,100,,,fee schedule,100% of bcbs custom fee schedule,49.6,100,,,fee schedule,100% of bcbs custom fee schedule,55.06,111,,,fee schedule,111% of bcbs custom fee schedule,117.5,50,,94,percent of total billed charges,50% of total billed charges,164.5,70,,131.6,percent of total billed charges,70% of total billed charges,113.93,48.48,,91.144,percent of total billed charges,48.48% of total billed charges,27.38,101,,,fee schedule,101% of cms custom fee schedule,113.93,48.48,,91.144,percent of total billed charges,48.48% of total billed charges,164.5,70,,131.6,percent of total billed charges,70% of total billed charges,164.5,70,,131.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,113.93,48.48,,91.144,percent of total billed charges,48.48% of total billed charges,211.5,90,,169.2,percent of total billed charges,90% of total billed charges,48.48,211.5,
RPR/VDRL TITER,,,300,RC,86593,HCPCS,outpatient,,,44,26.40,,26.4,60,,21.12,percent of total billed charges,60% of total billed charges,21.12,48,,16.896,percent of total billed charges,48% of total billed charges,13.35,100,,,fee schedule,100% of bcbs custom fee schedule,13.35,100,,,fee schedule,100% of bcbs custom fee schedule,14.82,111,,,fee schedule,111% of bcbs custom fee schedule,22,50,,17.6,percent of total billed charges,50% of total billed charges,30.8,70,,24.64,percent of total billed charges,70% of total billed charges,21.33,48.48,,17.064,percent of total billed charges,48.48% of total billed charges,4.44,101,,,fee schedule,101% of cms custom fee schedule,21.33,48.48,,17.064,percent of total billed charges,48.48% of total billed charges,30.8,70,,24.64,percent of total billed charges,70% of total billed charges,30.8,70,,24.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,21.33,48.48,,17.064,percent of total billed charges,48.48% of total billed charges,39.6,90,,31.68,percent of total billed charges,90% of total billed charges,21.33,90,
ELECTROLYTE PANEL,41000346,CDM,301,RC,80051,HCPCS,outpatient,,,68.75,41.25,,41.25,60,,33,percent of total billed charges,60% of total billed charges,33,48,,26.4,percent of total billed charges,48% of total billed charges,20.89,100,,,fee schedule,100% of bcbs custom fee schedule,20.89,100,,,fee schedule,100% of bcbs custom fee schedule,23.19,111,,,fee schedule,111% of bcbs custom fee schedule,34.38,50,,27.504,percent of total billed charges,50% of total billed charges,48.13,70,,38.504,percent of total billed charges,70% of total billed charges,33.33,48.48,,26.664,percent of total billed charges,48.48% of total billed charges,7.08,101,,,fee schedule,101% of cms custom fee schedule,33.33,48.48,,26.664,percent of total billed charges,48.48% of total billed charges,48.13,70,,38.504,percent of total billed charges,70% of total billed charges,48.13,70,,38.504,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,33.33,48.48,,26.664,percent of total billed charges,48.48% of total billed charges,61.88,90,,49.504,percent of total billed charges,90% of total billed charges,33.33,90,
"HIV-1 AG with HIV-1,2 ANTIBODIES",,,300,RC,87389,HCPCS,outpatient,,,260,156.00,,156,60,,124.8,percent of total billed charges,60% of total billed charges,124.8,48,,99.84,percent of total billed charges,48% of total billed charges,58.26,100,,,fee schedule,100% of bcbs custom fee schedule,58.26,100,,,fee schedule,100% of bcbs custom fee schedule,64.67,111,,,fee schedule,111% of bcbs custom fee schedule,130,50,,104,percent of total billed charges,50% of total billed charges,182,70,,145.6,percent of total billed charges,70% of total billed charges,126.05,48.48,,100.84,percent of total billed charges,48.48% of total billed charges,24.32,101,,,fee schedule,101% of cms custom fee schedule,126.05,48.48,,100.84,percent of total billed charges,48.48% of total billed charges,182,70,,145.6,percent of total billed charges,70% of total billed charges,182,70,,145.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,126.05,48.48,,100.84,percent of total billed charges,48.48% of total billed charges,234,90,,187.2,percent of total billed charges,90% of total billed charges,48.48,234,
C-PEPTIDE,41000321,CDM,300,RC,84681,HCPCS,outpatient,,,143,85.80,,85.8,60,,68.64,percent of total billed charges,60% of total billed charges,68.64,48,,54.912,percent of total billed charges,48% of total billed charges,63.02,100,,,fee schedule,100% of bcbs custom fee schedule,63.02,100,,,fee schedule,100% of bcbs custom fee schedule,69.95,111,,,fee schedule,111% of bcbs custom fee schedule,71.5,50,,57.2,percent of total billed charges,50% of total billed charges,100.1,70,,80.08,percent of total billed charges,70% of total billed charges,69.33,48.48,,55.464,percent of total billed charges,48.48% of total billed charges,21.02,101,,,fee schedule,101% of cms custom fee schedule,69.33,48.48,,55.464,percent of total billed charges,48.48% of total billed charges,100.1,70,,80.08,percent of total billed charges,70% of total billed charges,100.1,70,,80.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,69.33,48.48,,55.464,percent of total billed charges,48.48% of total billed charges,128.7,90,,102.96,percent of total billed charges,90% of total billed charges,48.48,128.7,
IgE,41009040,CDM,300,RC,82785,HCPCS,outpatient,,,250,150.00,,150,60,,120,percent of total billed charges,60% of total billed charges,120,48,,96,percent of total billed charges,48% of total billed charges,49.88,100,,,fee schedule,100% of bcbs custom fee schedule,49.88,100,,,fee schedule,100% of bcbs custom fee schedule,55.37,111,,,fee schedule,111% of bcbs custom fee schedule,125,50,,100,percent of total billed charges,50% of total billed charges,175,70,,140,percent of total billed charges,70% of total billed charges,121.2,48.48,,96.96,percent of total billed charges,48.48% of total billed charges,16.62,101,,,fee schedule,101% of cms custom fee schedule,121.2,48.48,,96.96,percent of total billed charges,48.48% of total billed charges,175,70,,140,percent of total billed charges,70% of total billed charges,175,70,,140,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,121.2,48.48,,96.96,percent of total billed charges,48.48% of total billed charges,225,90,,180,percent of total billed charges,90% of total billed charges,48.48,225,
GLUCOSE TOLERANCE (3 HR),41000067,CDM,301,RC,82951,HCPCS,outpatient,,,131.25,78.75,,78.75,60,,63,percent of total billed charges,60% of total billed charges,63,48,,50.4,percent of total billed charges,48% of total billed charges,39,100,,,fee schedule,100% of bcbs custom fee schedule,39,100,,,fee schedule,100% of bcbs custom fee schedule,43.29,111,,,fee schedule,111% of bcbs custom fee schedule,65.63,50,,52.504,percent of total billed charges,50% of total billed charges,91.88,70,,73.504,percent of total billed charges,70% of total billed charges,63.63,48.48,,50.904,percent of total billed charges,48.48% of total billed charges,13,101,,,fee schedule,101% of cms custom fee schedule,63.63,48.48,,50.904,percent of total billed charges,48.48% of total billed charges,91.88,70,,73.504,percent of total billed charges,70% of total billed charges,91.88,70,,73.504,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,63.63,48.48,,50.904,percent of total billed charges,48.48% of total billed charges,118.13,90,,94.504,percent of total billed charges,90% of total billed charges,48.48,118.13,
GTT-ADDED SAMPLES,41000910,CDM,301,RC,82952,HCPCS,outpatient,,,87.5,52.50,,52.5,60,,42,percent of total billed charges,60% of total billed charges,42,48,,33.6,percent of total billed charges,48% of total billed charges,11.88,100,,,fee schedule,100% of bcbs custom fee schedule,11.88,100,,,fee schedule,100% of bcbs custom fee schedule,13.19,111,,,fee schedule,111% of bcbs custom fee schedule,43.75,50,,35,percent of total billed charges,50% of total billed charges,61.25,70,,49,percent of total billed charges,70% of total billed charges,42.42,48.48,,33.936,percent of total billed charges,48.48% of total billed charges,3.96,101,,,fee schedule,101% of cms custom fee schedule,42.42,48.48,,33.936,percent of total billed charges,48.48% of total billed charges,61.25,70,,49,percent of total billed charges,70% of total billed charges,61.25,70,,49,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,42.42,48.48,,33.936,percent of total billed charges,48.48% of total billed charges,78.75,90,,63,percent of total billed charges,90% of total billed charges,42.42,90,
GLUCOSE-POST CHALLENGE,41000369,CDM,300,RC,82950,HCPCS,outpatient,,,60,36.00,91,36,60,,28.8,percent of total billed charges,60% of total billed charges,28.8,48,,23.04,percent of total billed charges,48% of total billed charges,14.39,100,,,fee schedule,100% of bcbs custom fee schedule,14.39,100,,,fee schedule,100% of bcbs custom fee schedule,15.97,111,,,fee schedule,111% of bcbs custom fee schedule,30,50,,24,percent of total billed charges,50% of total billed charges,42,70,,33.6,percent of total billed charges,70% of total billed charges,29.09,48.48,,23.272,percent of total billed charges,48.48% of total billed charges,4.8,101,,,fee schedule,101% of cms custom fee schedule,29.09,48.48,,23.272,percent of total billed charges,48.48% of total billed charges,42,70,,33.6,percent of total billed charges,70% of total billed charges,42,70,,33.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,29.09,48.48,,23.272,percent of total billed charges,48.48% of total billed charges,54,90,,43.2,percent of total billed charges,90% of total billed charges,29.09,90,
Clostridium difficile Antigen by EIA,41000373,CDM,300,RC,87449,HCPCS,outpatient,,,70.5,42.30,,42.3,60,,33.84,percent of total billed charges,60% of total billed charges,33.84,48,,27.072,percent of total billed charges,48% of total billed charges,36.33,100,,,fee schedule,100% of bcbs custom fee schedule,36.33,100,,,fee schedule,100% of bcbs custom fee schedule,40.33,111,,,fee schedule,111% of bcbs custom fee schedule,35.25,50,,28.2,percent of total billed charges,50% of total billed charges,49.35,70,,39.48,percent of total billed charges,70% of total billed charges,34.18,48.48,,27.344,percent of total billed charges,48.48% of total billed charges,12.1,101,,,fee schedule,101% of cms custom fee schedule,34.18,48.48,,27.344,percent of total billed charges,48.48% of total billed charges,49.35,70,,39.48,percent of total billed charges,70% of total billed charges,49.35,70,,39.48,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,34.18,48.48,,27.344,percent of total billed charges,48.48% of total billed charges,63.45,90,,50.76,percent of total billed charges,90% of total billed charges,34.18,90,
Port Access for Blood Collection,32000103,CDM,300,RC,36591,HCPCS,outpatient,,,75,45.00,,45,60,,36,percent of total billed charges,60% of total billed charges,36,48,,28.8,percent of total billed charges,48% of total billed charges,138.08,100,,,fee schedule,100% of bcbs custom fee schedule,138.08,100,,,fee schedule,100% of bcbs custom fee schedule,153.27,111,,,fee schedule,111% of bcbs custom fee schedule,37.5,50,,30,percent of total billed charges,50% of total billed charges,52.5,70,,42,percent of total billed charges,70% of total billed charges,36.36,48.48,,29.088,percent of total billed charges,48.48% of total billed charges,28.21,116.15,,,fee schedule,116.51% of cms physician fee schedule,36.36,48.48,,29.088,percent of total billed charges,48.48% of total billed charges,52.5,70,,42,percent of total billed charges,70% of total billed charges,52.5,70,,42,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,36.36,48.48,,29.088,percent of total billed charges,48.48% of total billed charges,67.5,90,,54,percent of total billed charges,90% of total billed charges,36.36,90,
Clostridium difficile by DNA Amplificati,41001188,CDM,300,RC,87493,HCPCS,outpatient,,,156.5,93.90,,93.9,60,,75.12,percent of total billed charges,60% of total billed charges,75.12,48,,60.096,percent of total billed charges,48% of total billed charges,75.68,100,,,fee schedule,100% of bcbs custom fee schedule,75.68,100,,,fee schedule,100% of bcbs custom fee schedule,84,111,,,fee schedule,111% of bcbs custom fee schedule,78.25,50,,62.6,percent of total billed charges,50% of total billed charges,109.55,70,,87.64,percent of total billed charges,70% of total billed charges,75.87,48.48,,60.696,percent of total billed charges,48.48% of total billed charges,37.64,101,,,fee schedule,101% of cms custom fee schedule,75.87,48.48,,60.696,percent of total billed charges,48.48% of total billed charges,109.55,70,,87.64,percent of total billed charges,70% of total billed charges,109.55,70,,87.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,75.87,48.48,,60.696,percent of total billed charges,48.48% of total billed charges,140.85,90,,112.68,percent of total billed charges,90% of total billed charges,48.48,140.85,
GRAM STAIN,41000302,CDM,306,RC,87205,HCPCS,outpatient,,,41.5,24.90,,24.9,60,,19.92,percent of total billed charges,60% of total billed charges,19.92,48,,15.936,percent of total billed charges,48% of total billed charges,12.91,100,,,fee schedule,100% of bcbs custom fee schedule,12.91,100,,,fee schedule,100% of bcbs custom fee schedule,14.33,111,,,fee schedule,111% of bcbs custom fee schedule,20.75,50,,16.6,percent of total billed charges,50% of total billed charges,29.05,70,,23.24,percent of total billed charges,70% of total billed charges,20.12,48.48,,16.096,percent of total billed charges,48.48% of total billed charges,4.31,101,,,fee schedule,101% of cms custom fee schedule,20.12,48.48,,16.096,percent of total billed charges,48.48% of total billed charges,29.05,70,,23.24,percent of total billed charges,70% of total billed charges,29.05,70,,23.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,20.12,48.48,,16.096,percent of total billed charges,48.48% of total billed charges,37.35,90,,29.88,percent of total billed charges,90% of total billed charges,20.12,90,
CULTURE AEROBIC,41000047,CDM,300,RC,87070,HCPCS,outpatient,,,183.75,110.25,,110.25,60,,88.2,percent of total billed charges,60% of total billed charges,88.2,48,,70.56,percent of total billed charges,48% of total billed charges,26.08,100,,,fee schedule,100% of bcbs custom fee schedule,26.08,100,,,fee schedule,100% of bcbs custom fee schedule,28.95,111,,,fee schedule,111% of bcbs custom fee schedule,91.88,50,,73.504,percent of total billed charges,50% of total billed charges,128.63,70,,102.904,percent of total billed charges,70% of total billed charges,89.08,48.48,,71.264,percent of total billed charges,48.48% of total billed charges,8.71,101,,,fee schedule,101% of cms custom fee schedule,89.08,48.48,,71.264,percent of total billed charges,48.48% of total billed charges,128.63,70,,102.904,percent of total billed charges,70% of total billed charges,128.63,70,,102.904,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,89.08,48.48,,71.264,percent of total billed charges,48.48% of total billed charges,165.38,90,,132.304,percent of total billed charges,90% of total billed charges,48.48,165.38,
HEMOGLOBIN,41000103,CDM,305,RC,85018,HCPCS,outpatient,,,22,13.20,,13.2,60,,10.56,percent of total billed charges,60% of total billed charges,10.56,48,,8.448,percent of total billed charges,48% of total billed charges,7.18,100,,,fee schedule,100% of bcbs custom fee schedule,7.18,100,,,fee schedule,100% of bcbs custom fee schedule,7.97,111,,,fee schedule,111% of bcbs custom fee schedule,11,50,,8.8,percent of total billed charges,50% of total billed charges,15.4,70,,12.32,percent of total billed charges,70% of total billed charges,10.67,48.48,,8.536,percent of total billed charges,48.48% of total billed charges,2.39,101,,,fee schedule,101% of cms custom fee schedule,10.67,48.48,,8.536,percent of total billed charges,48.48% of total billed charges,15.4,70,,12.32,percent of total billed charges,70% of total billed charges,15.4,70,,12.32,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,10.67,48.48,,8.536,percent of total billed charges,48.48% of total billed charges,19.8,90,,15.84,percent of total billed charges,90% of total billed charges,10.67,90,
CULTURE ANAEROBIC,,,300,RC,87073,HCPCS,outpatient,,,183.75,110.25,,110.25,60,,88.2,percent of total billed charges,60% of total billed charges,88.2,48,,70.56,percent of total billed charges,48% of total billed charges,28.57,100,,,fee schedule,100% of bcbs custom fee schedule,28.57,100,,,fee schedule,100% of bcbs custom fee schedule,31.71,111,,,fee schedule,111% of bcbs custom fee schedule,91.88,50,,73.504,percent of total billed charges,50% of total billed charges,128.63,70,,102.904,percent of total billed charges,70% of total billed charges,89.08,48.48,,71.264,percent of total billed charges,48.48% of total billed charges,9.76,101,,,fee schedule,101% of cms custom fee schedule,89.08,48.48,,71.264,percent of total billed charges,48.48% of total billed charges,128.63,70,,102.904,percent of total billed charges,70% of total billed charges,128.63,70,,102.904,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,89.08,48.48,,71.264,percent of total billed charges,48.48% of total billed charges,165.38,90,,132.304,percent of total billed charges,90% of total billed charges,48.48,165.38,
HEMATOCRIT,41000104,CDM,305,RC,85014,HCPCS,outpatient,,,22.5,13.50,,13.5,60,,10.8,percent of total billed charges,60% of total billed charges,10.8,48,,8.64,percent of total billed charges,48% of total billed charges,7.18,100,,,fee schedule,100% of bcbs custom fee schedule,7.18,100,,,fee schedule,100% of bcbs custom fee schedule,7.97,111,,,fee schedule,111% of bcbs custom fee schedule,11.25,50,,9,percent of total billed charges,50% of total billed charges,15.75,70,,12.6,percent of total billed charges,70% of total billed charges,10.91,48.48,,8.728,percent of total billed charges,48.48% of total billed charges,2.39,101,,,fee schedule,101% of cms custom fee schedule,10.91,48.48,,8.728,percent of total billed charges,48.48% of total billed charges,15.75,70,,12.6,percent of total billed charges,70% of total billed charges,15.75,70,,12.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,10.91,48.48,,8.728,percent of total billed charges,48.48% of total billed charges,20.25,90,,16.2,percent of total billed charges,90% of total billed charges,10.91,90,
HERPES SYMPLEX TYPE 1 ANTIBODIES,41001039,CDM,300,RC,86695,HCPCS,outpatient,,,105,63.00,,63,60,,50.4,percent of total billed charges,60% of total billed charges,50.4,48,,40.32,percent of total billed charges,48% of total billed charges,39.95,100,,,fee schedule,100% of bcbs custom fee schedule,39.95,100,,,fee schedule,100% of bcbs custom fee schedule,44.34,111,,,fee schedule,111% of bcbs custom fee schedule,52.5,50,,42,percent of total billed charges,50% of total billed charges,73.5,70,,58.8,percent of total billed charges,70% of total billed charges,50.9,48.48,,40.72,percent of total billed charges,48.48% of total billed charges,13.32,101,,,fee schedule,101% of cms custom fee schedule,50.9,48.48,,40.72,percent of total billed charges,48.48% of total billed charges,73.5,70,,58.8,percent of total billed charges,70% of total billed charges,73.5,70,,58.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,50.9,48.48,,40.72,percent of total billed charges,48.48% of total billed charges,94.5,90,,75.6,percent of total billed charges,90% of total billed charges,48.48,94.5,
"Vasopressin (antidiuretic hormone, ADH)",41000393,CDM,300,RC,84588,HCPCS,outpatient,,,457.5,274.50,,274.5,60,,219.6,percent of total billed charges,60% of total billed charges,219.6,48,,175.68,percent of total billed charges,48% of total billed charges,102.82,100,,,fee schedule,100% of bcbs custom fee schedule,102.82,100,,,fee schedule,100% of bcbs custom fee schedule,114.13,111,,,fee schedule,111% of bcbs custom fee schedule,228.75,50,,183,percent of total billed charges,50% of total billed charges,320.25,70,,256.2,percent of total billed charges,70% of total billed charges,221.8,48.48,,177.44,percent of total billed charges,48.48% of total billed charges,34.28,101,,,fee schedule,101% of cms custom fee schedule,221.8,48.48,,177.44,percent of total billed charges,48.48% of total billed charges,320.25,70,,256.2,percent of total billed charges,70% of total billed charges,320.25,70,,256.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,221.8,48.48,,177.44,percent of total billed charges,48.48% of total billed charges,411.75,90,,329.4,percent of total billed charges,90% of total billed charges,48.48,411.75,
"ROTAVIRUS, STOOL",41000437,CDM,300,RC,87425,HCPCS,outpatient,,,137.5,82.50,,82.5,60,,66,percent of total billed charges,60% of total billed charges,66,48,,52.8,percent of total billed charges,48% of total billed charges,36.33,100,,,fee schedule,100% of bcbs custom fee schedule,36.33,100,,,fee schedule,100% of bcbs custom fee schedule,40.33,111,,,fee schedule,111% of bcbs custom fee schedule,68.75,50,,55,percent of total billed charges,50% of total billed charges,96.25,70,,77,percent of total billed charges,70% of total billed charges,66.66,48.48,,53.328,percent of total billed charges,48.48% of total billed charges,12.1,101,,,fee schedule,101% of cms custom fee schedule,66.66,48.48,,53.328,percent of total billed charges,48.48% of total billed charges,96.25,70,,77,percent of total billed charges,70% of total billed charges,96.25,70,,77,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,66.66,48.48,,53.328,percent of total billed charges,48.48% of total billed charges,123.75,90,,99,percent of total billed charges,90% of total billed charges,48.48,123.75,
LDH (Plain),41000011,CDM,301,RC,83615,HCPCS,outpatient,,,74,44.40,,44.4,60,,35.52,percent of total billed charges,60% of total billed charges,35.52,48,,28.416,percent of total billed charges,48% of total billed charges,18.3,100,,,fee schedule,100% of bcbs custom fee schedule,18.3,100,,,fee schedule,100% of bcbs custom fee schedule,20.31,111,,,fee schedule,111% of bcbs custom fee schedule,37,50,,29.6,percent of total billed charges,50% of total billed charges,51.8,70,,41.44,percent of total billed charges,70% of total billed charges,35.88,48.48,,28.704,percent of total billed charges,48.48% of total billed charges,6.1,101,,,fee schedule,101% of cms custom fee schedule,35.88,48.48,,28.704,percent of total billed charges,48.48% of total billed charges,51.8,70,,41.44,percent of total billed charges,70% of total billed charges,51.8,70,,41.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,35.88,48.48,,28.704,percent of total billed charges,48.48% of total billed charges,66.6,90,,53.28,percent of total billed charges,90% of total billed charges,35.88,90,
STOOL LEUKOCYTES,41000424,CDM,300,RC,89055,HCPCS,outpatient,,,93.75,56.25,,56.25,60,,45,percent of total billed charges,60% of total billed charges,45,48,,36,percent of total billed charges,48% of total billed charges,12.91,100,,,fee schedule,100% of bcbs custom fee schedule,12.91,100,,,fee schedule,100% of bcbs custom fee schedule,14.33,111,,,fee schedule,111% of bcbs custom fee schedule,46.88,50,,37.504,percent of total billed charges,50% of total billed charges,65.63,70,,52.504,percent of total billed charges,70% of total billed charges,45.45,48.48,,36.36,percent of total billed charges,48.48% of total billed charges,4.31,101,,,fee schedule,101% of cms custom fee schedule,45.45,48.48,,36.36,percent of total billed charges,48.48% of total billed charges,65.63,70,,52.504,percent of total billed charges,70% of total billed charges,65.63,70,,52.504,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,45.45,48.48,,36.36,percent of total billed charges,48.48% of total billed charges,84.38,90,,67.504,percent of total billed charges,90% of total billed charges,45.45,90,
"Fecal Fat, Qualitative",41000052,CDM,300,RC,82705,HCPCS,outpatient,,,45,27.00,,27,60,,21.6,percent of total billed charges,60% of total billed charges,21.6,48,,17.28,percent of total billed charges,48% of total billed charges,15.41,100,,,fee schedule,100% of bcbs custom fee schedule,15.41,100,,,fee schedule,100% of bcbs custom fee schedule,17.11,111,,,fee schedule,111% of bcbs custom fee schedule,22.5,50,,18,percent of total billed charges,50% of total billed charges,31.5,70,,25.2,percent of total billed charges,70% of total billed charges,21.82,48.48,,17.456,percent of total billed charges,48.48% of total billed charges,5.15,101,,,fee schedule,101% of cms custom fee schedule,21.82,48.48,,17.456,percent of total billed charges,48.48% of total billed charges,31.5,70,,25.2,percent of total billed charges,70% of total billed charges,31.5,70,,25.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,21.82,48.48,,17.456,percent of total billed charges,48.48% of total billed charges,40.5,90,,32.4,percent of total billed charges,90% of total billed charges,21.82,90,
BETA-2 MICROGLOBULIN,41000445,CDM,300,RC,82232,HCPCS,outpatient,,,50,30.00,,30,60,,24,percent of total billed charges,60% of total billed charges,24,48,,19.2,percent of total billed charges,48% of total billed charges,49.02,100,,,fee schedule,100% of bcbs custom fee schedule,49.02,100,,,fee schedule,100% of bcbs custom fee schedule,54.41,111,,,fee schedule,111% of bcbs custom fee schedule,25,50,,20,percent of total billed charges,50% of total billed charges,35,70,,28,percent of total billed charges,70% of total billed charges,24.24,48.48,,19.392,percent of total billed charges,48.48% of total billed charges,16.34,101,,,fee schedule,101% of cms custom fee schedule,24.24,48.48,,19.392,percent of total billed charges,48.48% of total billed charges,35,70,,28,percent of total billed charges,70% of total billed charges,35,70,,28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,24.24,48.48,,19.392,percent of total billed charges,48.48% of total billed charges,45,90,,36,percent of total billed charges,90% of total billed charges,24.24,90,
LIPID PANEL,41000757,CDM,301,RC,80061,HCPCS,outpatient,,,97.5,58.50,,58.5,60,,46.8,percent of total billed charges,60% of total billed charges,46.8,48,,37.44,percent of total billed charges,48% of total billed charges,36.18,100,,,fee schedule,100% of bcbs custom fee schedule,36.18,100,,,fee schedule,100% of bcbs custom fee schedule,40.16,111,,,fee schedule,111% of bcbs custom fee schedule,48.75,50,,39,percent of total billed charges,50% of total billed charges,68.25,70,,54.6,percent of total billed charges,70% of total billed charges,47.27,48.48,,37.816,percent of total billed charges,48.48% of total billed charges,13.52,101,,,fee schedule,101% of cms custom fee schedule,47.27,48.48,,37.816,percent of total billed charges,48.48% of total billed charges,68.25,70,,54.6,percent of total billed charges,70% of total billed charges,68.25,70,,54.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,47.27,48.48,,37.816,percent of total billed charges,48.48% of total billed charges,87.75,90,,70.2,percent of total billed charges,90% of total billed charges,47.27,90,
AMPLIFIED PROBE TECHNIQUE CT GC BY PCR,,,300,RC,87801,HCPCS,outpatient,,,396.5,237.90,,237.9,60,,190.32,percent of total billed charges,60% of total billed charges,190.32,48,,152.256,percent of total billed charges,48% of total billed charges,212.6,100,,,fee schedule,100% of bcbs custom fee schedule,212.6,100,,,fee schedule,100% of bcbs custom fee schedule,235.99,111,,,fee schedule,111% of bcbs custom fee schedule,198.25,50,,158.6,percent of total billed charges,50% of total billed charges,277.55,70,,222.04,percent of total billed charges,70% of total billed charges,192.22,48.48,,153.776,percent of total billed charges,48.48% of total billed charges,70.9,101,,,fee schedule,101% of cms custom fee schedule,192.22,48.48,,153.776,percent of total billed charges,48.48% of total billed charges,277.55,70,,222.04,percent of total billed charges,70% of total billed charges,277.55,70,,222.04,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,192.22,48.48,,153.776,percent of total billed charges,48.48% of total billed charges,356.85,90,,285.48,percent of total billed charges,90% of total billed charges,48.48,356.85,
HEPATIC FUNCTION PANEL,41000139,CDM,301,RC,80076,HCPCS,outpatient,,,113.75,68.25,,68.25,60,,54.6,percent of total billed charges,60% of total billed charges,54.6,48,,43.68,percent of total billed charges,48% of total billed charges,24.75,100,,,fee schedule,100% of bcbs custom fee schedule,24.75,100,,,fee schedule,100% of bcbs custom fee schedule,27.47,111,,,fee schedule,111% of bcbs custom fee schedule,56.88,50,,45.504,percent of total billed charges,50% of total billed charges,79.63,70,,63.704,percent of total billed charges,70% of total billed charges,55.15,48.48,,44.12,percent of total billed charges,48.48% of total billed charges,8.25,101,,,fee schedule,101% of cms custom fee schedule,55.15,48.48,,44.12,percent of total billed charges,48.48% of total billed charges,79.63,70,,63.704,percent of total billed charges,70% of total billed charges,79.63,70,,63.704,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,55.15,48.48,,44.12,percent of total billed charges,48.48% of total billed charges,102.38,90,,81.904,percent of total billed charges,90% of total billed charges,48.48,102.38,
AMIKACIN LEVEL,41000303,CDM,300,RC,80150,HCPCS,outpatient,,,128.5,77.10,91,77.1,60,,61.68,percent of total billed charges,60% of total billed charges,61.68,48,,49.344,percent of total billed charges,48% of total billed charges,35.24,100,,,fee schedule,100% of bcbs custom fee schedule,35.24,100,,,fee schedule,100% of bcbs custom fee schedule,39.12,111,,,fee schedule,111% of bcbs custom fee schedule,64.25,50,,51.4,percent of total billed charges,50% of total billed charges,89.95,70,,71.96,percent of total billed charges,70% of total billed charges,62.3,48.48,,49.84,percent of total billed charges,48.48% of total billed charges,15.23,101,,,fee schedule,101% of cms custom fee schedule,62.3,48.48,,49.84,percent of total billed charges,48.48% of total billed charges,89.95,70,,71.96,percent of total billed charges,70% of total billed charges,89.95,70,,71.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,62.3,48.48,,49.84,percent of total billed charges,48.48% of total billed charges,115.65,90,,92.52,percent of total billed charges,90% of total billed charges,48.48,115.65,
MONO TEST,41000906,CDM,302,RC,86308,HCPCS,outpatient,,,44,26.40,QW,26.4,60,,21.12,percent of total billed charges,60% of total billed charges,21.12,48,,16.896,percent of total billed charges,48% of total billed charges,15.67,100,,,fee schedule,100% of bcbs custom fee schedule,15.67,100,,,fee schedule,100% of bcbs custom fee schedule,17.39,111,,,fee schedule,111% of bcbs custom fee schedule,22,50,,17.6,percent of total billed charges,50% of total billed charges,30.8,70,,24.64,percent of total billed charges,70% of total billed charges,21.33,48.48,,17.064,percent of total billed charges,48.48% of total billed charges,5.23,101,,,fee schedule,101% of cms custom fee schedule,21.33,48.48,,17.064,percent of total billed charges,48.48% of total billed charges,30.8,70,,24.64,percent of total billed charges,70% of total billed charges,30.8,70,,24.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,21.33,48.48,,17.064,percent of total billed charges,48.48% of total billed charges,39.6,90,,31.68,percent of total billed charges,90% of total billed charges,21.33,90,
ACUTE HEPATITIS PANEL,41000912,CDM,300,RC,80074,HCPCS,outpatient,,,358.5,215.10,,215.1,60,,172.08,percent of total billed charges,60% of total billed charges,172.08,48,,137.664,percent of total billed charges,48% of total billed charges,144.25,100,,,fee schedule,100% of bcbs custom fee schedule,144.25,100,,,fee schedule,100% of bcbs custom fee schedule,160.12,111,,,fee schedule,111% of bcbs custom fee schedule,179.25,50,,143.4,percent of total billed charges,50% of total billed charges,250.95,70,,200.76,percent of total billed charges,70% of total billed charges,173.8,48.48,,139.04,percent of total billed charges,48.48% of total billed charges,48.11,101,,,fee schedule,101% of cms custom fee schedule,173.8,48.48,,139.04,percent of total billed charges,48.48% of total billed charges,250.95,70,,200.76,percent of total billed charges,70% of total billed charges,250.95,70,,200.76,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,173.8,48.48,,139.04,percent of total billed charges,48.48% of total billed charges,322.65,90,,258.12,percent of total billed charges,90% of total billed charges,48.48,322.65,
OCP OVA & PARASITE CON.,,,306,RC,87177,HCPCS,outpatient,,,63.5,38.10,,38.1,60,,30.48,percent of total billed charges,60% of total billed charges,30.48,48,,24.384,percent of total billed charges,48% of total billed charges,26.5,100,,,fee schedule,100% of bcbs custom fee schedule,26.5,100,,,fee schedule,100% of bcbs custom fee schedule,29.42,111,,,fee schedule,111% of bcbs custom fee schedule,31.75,50,,25.4,percent of total billed charges,50% of total billed charges,44.45,70,,35.56,percent of total billed charges,70% of total billed charges,30.78,48.48,,24.624,percent of total billed charges,48.48% of total billed charges,8.99,101,,,fee schedule,101% of cms custom fee schedule,30.78,48.48,,24.624,percent of total billed charges,48.48% of total billed charges,44.45,70,,35.56,percent of total billed charges,70% of total billed charges,44.45,70,,35.56,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,30.78,48.48,,24.624,percent of total billed charges,48.48% of total billed charges,57.15,90,,45.72,percent of total billed charges,90% of total billed charges,30.78,90,
HERPES SYMPLEX TYPE 2 ANTIBODIES,41001040,CDM,300,RC,86696,HCPCS,outpatient,,,146,87.60,,87.6,60,,70.08,percent of total billed charges,60% of total billed charges,70.08,48,,56.064,percent of total billed charges,48% of total billed charges,58.64,100,,,fee schedule,100% of bcbs custom fee schedule,58.64,100,,,fee schedule,100% of bcbs custom fee schedule,65.09,111,,,fee schedule,111% of bcbs custom fee schedule,73,50,,58.4,percent of total billed charges,50% of total billed charges,102.2,70,,81.76,percent of total billed charges,70% of total billed charges,70.78,48.48,,56.624,percent of total billed charges,48.48% of total billed charges,19.54,101,,,fee schedule,101% of cms custom fee schedule,70.78,48.48,,56.624,percent of total billed charges,48.48% of total billed charges,102.2,70,,81.76,percent of total billed charges,70% of total billed charges,102.2,70,,81.76,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,70.78,48.48,,56.624,percent of total billed charges,48.48% of total billed charges,131.4,90,,105.12,percent of total billed charges,90% of total billed charges,48.48,131.4,
OCCULT BLOOD STOOL,41001107,CDM,301,RC,82272,HCPCS,outpatient,,,27.5,16.50,,16.5,60,,13.2,percent of total billed charges,60% of total billed charges,13.2,48,,10.56,percent of total billed charges,48% of total billed charges,8.3,100,,,fee schedule,100% of bcbs custom fee schedule,8.3,100,,,fee schedule,100% of bcbs custom fee schedule,9.21,111,,,fee schedule,111% of bcbs custom fee schedule,13.75,50,,11,percent of total billed charges,50% of total billed charges,19.25,70,,15.4,percent of total billed charges,70% of total billed charges,13.33,48.48,,10.664,percent of total billed charges,48.48% of total billed charges,4.27,101,,,fee schedule,101% of cms custom fee schedule,13.33,48.48,,10.664,percent of total billed charges,48.48% of total billed charges,19.25,70,,15.4,percent of total billed charges,70% of total billed charges,19.25,70,,15.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,13.33,48.48,,10.664,percent of total billed charges,48.48% of total billed charges,24.75,90,,19.8,percent of total billed charges,90% of total billed charges,13.33,90,
TRICHROME STAIN,41000512,CDM,300,RC,87209,HCPCS,outpatient,,,116,69.60,,69.6,60,,55.68,percent of total billed charges,60% of total billed charges,55.68,48,,44.544,percent of total billed charges,48% of total billed charges,45.94,100,,,fee schedule,100% of bcbs custom fee schedule,45.94,100,,,fee schedule,100% of bcbs custom fee schedule,50.99,111,,,fee schedule,111% of bcbs custom fee schedule,58,50,,46.4,percent of total billed charges,50% of total billed charges,81.2,70,,64.96,percent of total billed charges,70% of total billed charges,56.24,48.48,,44.992,percent of total billed charges,48.48% of total billed charges,18.16,101,,,fee schedule,101% of cms custom fee schedule,56.24,48.48,,44.992,percent of total billed charges,48.48% of total billed charges,81.2,70,,64.96,percent of total billed charges,70% of total billed charges,81.2,70,,64.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,56.24,48.48,,44.992,percent of total billed charges,48.48% of total billed charges,104.4,90,,83.52,percent of total billed charges,90% of total billed charges,48.48,104.4,
PHOSPHORUS LEVEL,41000063,CDM,301,RC,84100,HCPCS,outpatient,,,75,45.00,,45,60,,36,percent of total billed charges,60% of total billed charges,36,48,,28.8,percent of total billed charges,48% of total billed charges,14.38,100,,,fee schedule,100% of bcbs custom fee schedule,14.38,100,,,fee schedule,100% of bcbs custom fee schedule,15.96,111,,,fee schedule,111% of bcbs custom fee schedule,37.5,50,,30,percent of total billed charges,50% of total billed charges,52.5,70,,42,percent of total billed charges,70% of total billed charges,36.36,48.48,,29.088,percent of total billed charges,48.48% of total billed charges,4.79,101,,,fee schedule,101% of cms custom fee schedule,36.36,48.48,,29.088,percent of total billed charges,48.48% of total billed charges,52.5,70,,42,percent of total billed charges,70% of total billed charges,52.5,70,,42,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,36.36,48.48,,29.088,percent of total billed charges,48.48% of total billed charges,67.5,90,,54,percent of total billed charges,90% of total billed charges,36.36,90,
"INSULIN LEVEL, TOTAL",41009016,CDM,300,RC,83525,HCPCS,outpatient,,,183.75,110.25,,110.25,60,,88.2,percent of total billed charges,60% of total billed charges,88.2,48,,70.56,percent of total billed charges,48% of total billed charges,34.64,100,,,fee schedule,100% of bcbs custom fee schedule,34.64,100,,,fee schedule,100% of bcbs custom fee schedule,38.45,111,,,fee schedule,111% of bcbs custom fee schedule,91.88,50,,73.504,percent of total billed charges,50% of total billed charges,128.63,70,,102.904,percent of total billed charges,70% of total billed charges,89.08,48.48,,71.264,percent of total billed charges,48.48% of total billed charges,11.54,101,,,fee schedule,101% of cms custom fee schedule,89.08,48.48,,71.264,percent of total billed charges,48.48% of total billed charges,128.63,70,,102.904,percent of total billed charges,70% of total billed charges,128.63,70,,102.904,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,89.08,48.48,,71.264,percent of total billed charges,48.48% of total billed charges,165.38,90,,132.304,percent of total billed charges,90% of total billed charges,48.48,165.38,
TRAB/TSH Receptor Binding Antibody,41000540,CDM,300,RC,83520,HCPCS,outpatient,,,230,138.00,,138,60,,110.4,percent of total billed charges,60% of total billed charges,110.4,48,,88.32,percent of total billed charges,48% of total billed charges,39.22,100,,,fee schedule,100% of bcbs custom fee schedule,39.22,100,,,fee schedule,100% of bcbs custom fee schedule,43.53,111,,,fee schedule,111% of bcbs custom fee schedule,115,50,,92,percent of total billed charges,50% of total billed charges,161,70,,128.8,percent of total billed charges,70% of total billed charges,111.5,48.48,,89.2,percent of total billed charges,48.48% of total billed charges,17.44,101,,,fee schedule,101% of cms custom fee schedule,111.5,48.48,,89.2,percent of total billed charges,48.48% of total billed charges,161,70,,128.8,percent of total billed charges,70% of total billed charges,161,70,,128.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,111.5,48.48,,89.2,percent of total billed charges,48.48% of total billed charges,207,90,,165.6,percent of total billed charges,90% of total billed charges,48.48,207,
"IDENTIFICATION, AEROBIC",41000094,CDM,300,RC,87077,HCPCS,outpatient,,,83.75,50.25,,50.25,60,,40.2,percent of total billed charges,60% of total billed charges,40.2,48,,32.16,percent of total billed charges,48% of total billed charges,24.48,100,,,fee schedule,100% of bcbs custom fee schedule,24.48,100,,,fee schedule,100% of bcbs custom fee schedule,27.17,111,,,fee schedule,111% of bcbs custom fee schedule,41.88,50,,33.504,percent of total billed charges,50% of total billed charges,58.63,70,,46.904,percent of total billed charges,70% of total billed charges,40.6,48.48,,32.48,percent of total billed charges,48.48% of total billed charges,8.16,101,,,fee schedule,101% of cms custom fee schedule,40.6,48.48,,32.48,percent of total billed charges,48.48% of total billed charges,58.63,70,,46.904,percent of total billed charges,70% of total billed charges,58.63,70,,46.904,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,40.6,48.48,,32.48,percent of total billed charges,48.48% of total billed charges,75.38,90,,60.304,percent of total billed charges,90% of total billed charges,40.6,90,
"IDENTIFICATION, ANAEROBIC",,,300,RC,87076,HCPCS,outpatient,,,83.75,50.25,,50.25,60,,40.2,percent of total billed charges,60% of total billed charges,40.2,48,,32.16,percent of total billed charges,48% of total billed charges,24.48,100,,,fee schedule,100% of bcbs custom fee schedule,24.48,100,,,fee schedule,100% of bcbs custom fee schedule,27.17,111,,,fee schedule,111% of bcbs custom fee schedule,41.88,50,,33.504,percent of total billed charges,50% of total billed charges,58.63,70,,46.904,percent of total billed charges,70% of total billed charges,40.6,48.48,,32.48,percent of total billed charges,48.48% of total billed charges,8.16,101,,,fee schedule,101% of cms custom fee schedule,40.6,48.48,,32.48,percent of total billed charges,48.48% of total billed charges,58.63,70,,46.904,percent of total billed charges,70% of total billed charges,58.63,70,,46.904,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,40.6,48.48,,32.48,percent of total billed charges,48.48% of total billed charges,75.38,90,,60.304,percent of total billed charges,90% of total billed charges,40.6,90,
TOTAL T4 (THYROXINE),41000902,CDM,300,RC,84436,HCPCS,outpatient,,,81.5,48.90,,48.9,60,,39.12,percent of total billed charges,60% of total billed charges,39.12,48,,31.296,percent of total billed charges,48% of total billed charges,14.65,100,,,fee schedule,100% of bcbs custom fee schedule,14.65,100,,,fee schedule,100% of bcbs custom fee schedule,16.26,111,,,fee schedule,111% of bcbs custom fee schedule,40.75,50,,32.6,percent of total billed charges,50% of total billed charges,57.05,70,,45.64,percent of total billed charges,70% of total billed charges,39.51,48.48,,31.608,percent of total billed charges,48.48% of total billed charges,6.94,101,,,fee schedule,101% of cms custom fee schedule,39.51,48.48,,31.608,percent of total billed charges,48.48% of total billed charges,57.05,70,,45.64,percent of total billed charges,70% of total billed charges,57.05,70,,45.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,39.51,48.48,,31.608,percent of total billed charges,48.48% of total billed charges,73.35,90,,58.68,percent of total billed charges,90% of total billed charges,39.51,90,
POTASSIUM,41000074,CDM,301,RC,84132,HCPCS,outpatient,,,74,44.40,,44.4,60,,35.52,percent of total billed charges,60% of total billed charges,35.52,48,,28.416,percent of total billed charges,48% of total billed charges,13.91,100,,,fee schedule,100% of bcbs custom fee schedule,13.91,100,,,fee schedule,100% of bcbs custom fee schedule,15.44,111,,,fee schedule,111% of bcbs custom fee schedule,37,50,,29.6,percent of total billed charges,50% of total billed charges,51.8,70,,41.44,percent of total billed charges,70% of total billed charges,35.88,48.48,,28.704,percent of total billed charges,48.48% of total billed charges,4.81,101,,,fee schedule,101% of cms custom fee schedule,35.88,48.48,,28.704,percent of total billed charges,48.48% of total billed charges,51.8,70,,41.44,percent of total billed charges,70% of total billed charges,51.8,70,,41.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,35.88,48.48,,28.704,percent of total billed charges,48.48% of total billed charges,66.6,90,,53.28,percent of total billed charges,90% of total billed charges,35.88,90,
THIAMINE VITAMIN B1,41001095,CDM,300,RC,84425,HCPCS,outpatient,,,143,85.80,,85.8,60,,68.64,percent of total billed charges,60% of total billed charges,68.64,48,,54.912,percent of total billed charges,48% of total billed charges,64.32,100,,,fee schedule,100% of bcbs custom fee schedule,64.32,100,,,fee schedule,100% of bcbs custom fee schedule,71.4,111,,,fee schedule,111% of bcbs custom fee schedule,71.5,50,,57.2,percent of total billed charges,50% of total billed charges,100.1,70,,80.08,percent of total billed charges,70% of total billed charges,69.33,48.48,,55.464,percent of total billed charges,48.48% of total billed charges,21.44,101,,,fee schedule,101% of cms custom fee schedule,69.33,48.48,,55.464,percent of total billed charges,48.48% of total billed charges,100.1,70,,80.08,percent of total billed charges,70% of total billed charges,100.1,70,,80.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,69.33,48.48,,55.464,percent of total billed charges,48.48% of total billed charges,128.7,90,,102.96,percent of total billed charges,90% of total billed charges,48.48,128.7,
PROTHROMBIN TIME,41000119,CDM,305,RC,85610,HCPCS,outpatient,,,45,27.00,,27,60,,21.6,percent of total billed charges,60% of total billed charges,21.6,48,,17.28,percent of total billed charges,48% of total billed charges,11.9,100,,,fee schedule,100% of bcbs custom fee schedule,11.9,100,,,fee schedule,100% of bcbs custom fee schedule,13.21,111,,,fee schedule,111% of bcbs custom fee schedule,22.5,50,,18,percent of total billed charges,50% of total billed charges,31.5,70,,25.2,percent of total billed charges,70% of total billed charges,21.82,48.48,,17.456,percent of total billed charges,48.48% of total billed charges,4.33,101,,,fee schedule,101% of cms custom fee schedule,21.82,48.48,,17.456,percent of total billed charges,48.48% of total billed charges,31.5,70,,25.2,percent of total billed charges,70% of total billed charges,31.5,70,,25.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,21.82,48.48,,17.456,percent of total billed charges,48.48% of total billed charges,40.5,90,,32.4,percent of total billed charges,90% of total billed charges,21.82,90,
"PROTEIN, URINE TOTAL",41000434,CDM,300,RC,84156,HCPCS,outpatient,,,110,66.00,,66,60,,52.8,percent of total billed charges,60% of total billed charges,52.8,48,,42.24,percent of total billed charges,48% of total billed charges,11.09,100,,,fee schedule,100% of bcbs custom fee schedule,11.09,100,,,fee schedule,100% of bcbs custom fee schedule,12.31,111,,,fee schedule,111% of bcbs custom fee schedule,55,50,,44,percent of total billed charges,50% of total billed charges,77,70,,61.6,percent of total billed charges,70% of total billed charges,53.33,48.48,,42.664,percent of total billed charges,48.48% of total billed charges,3.71,101,,,fee schedule,101% of cms custom fee schedule,53.33,48.48,,42.664,percent of total billed charges,48.48% of total billed charges,77,70,,61.6,percent of total billed charges,70% of total billed charges,77,70,,61.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,53.33,48.48,,42.664,percent of total billed charges,48.48% of total billed charges,99,90,,79.2,percent of total billed charges,90% of total billed charges,48.48,99,
CEFINASE/ Carba Resistance,,,300,RC,87185,HCPCS,outpatient,,,45,27.00,,27,60,,21.6,percent of total billed charges,60% of total billed charges,21.6,48,,17.28,percent of total billed charges,48% of total billed charges,14.39,100,,,fee schedule,100% of bcbs custom fee schedule,14.39,100,,,fee schedule,100% of bcbs custom fee schedule,15.97,111,,,fee schedule,111% of bcbs custom fee schedule,22.5,50,,18,percent of total billed charges,50% of total billed charges,31.5,70,,25.2,percent of total billed charges,70% of total billed charges,21.82,48.48,,17.456,percent of total billed charges,48.48% of total billed charges,4.8,101,,,fee schedule,101% of cms custom fee schedule,21.82,48.48,,17.456,percent of total billed charges,48.48% of total billed charges,31.5,70,,25.2,percent of total billed charges,70% of total billed charges,31.5,70,,25.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,21.82,48.48,,17.456,percent of total billed charges,48.48% of total billed charges,40.5,90,,32.4,percent of total billed charges,90% of total billed charges,21.82,90,
TSI/Thyroid Stimulating Immunoglobulin,41000254,CDM,300,RC,84445,HCPCS,outpatient,,,185,111.00,,111,60,,88.8,percent of total billed charges,60% of total billed charges,88.8,48,,71.04,percent of total billed charges,48% of total billed charges,55.73,100,,,fee schedule,100% of bcbs custom fee schedule,55.73,100,,,fee schedule,100% of bcbs custom fee schedule,61.86,111,,,fee schedule,111% of bcbs custom fee schedule,92.5,50,,74,percent of total billed charges,50% of total billed charges,129.5,70,,103.6,percent of total billed charges,70% of total billed charges,89.69,48.48,,71.752,percent of total billed charges,48.48% of total billed charges,51.37,101,,,fee schedule,101% of cms custom fee schedule,89.69,48.48,,71.752,percent of total billed charges,48.48% of total billed charges,129.5,70,,103.6,percent of total billed charges,70% of total billed charges,129.5,70,,103.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,89.69,48.48,,71.752,percent of total billed charges,48.48% of total billed charges,166.5,90,,133.2,percent of total billed charges,90% of total billed charges,48.48,166.5,
PROTEIN-TOTAL,41000024,CDM,301,RC,84155,HCPCS,outpatient,,,68,40.80,,40.8,60,,32.64,percent of total billed charges,60% of total billed charges,32.64,48,,26.112,percent of total billed charges,48% of total billed charges,11.09,100,,,fee schedule,100% of bcbs custom fee schedule,11.09,100,,,fee schedule,100% of bcbs custom fee schedule,12.31,111,,,fee schedule,111% of bcbs custom fee schedule,34,50,,27.2,percent of total billed charges,50% of total billed charges,47.6,70,,38.08,percent of total billed charges,70% of total billed charges,32.97,48.48,,26.376,percent of total billed charges,48.48% of total billed charges,3.71,101,,,fee schedule,101% of cms custom fee schedule,32.97,48.48,,26.376,percent of total billed charges,48.48% of total billed charges,47.6,70,,38.08,percent of total billed charges,70% of total billed charges,47.6,70,,38.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,32.97,48.48,,26.376,percent of total billed charges,48.48% of total billed charges,61.2,90,,48.96,percent of total billed charges,90% of total billed charges,32.97,90,
LEAD LEVEL,41000042,CDM,300,RC,83655,HCPCS,outpatient,,,110,66.00,,66,60,,52.8,percent of total billed charges,60% of total billed charges,52.8,48,,42.24,percent of total billed charges,48% of total billed charges,36.66,100,,,fee schedule,100% of bcbs custom fee schedule,36.66,100,,,fee schedule,100% of bcbs custom fee schedule,40.69,111,,,fee schedule,111% of bcbs custom fee schedule,55,50,,44,percent of total billed charges,50% of total billed charges,77,70,,61.6,percent of total billed charges,70% of total billed charges,53.33,48.48,,42.664,percent of total billed charges,48.48% of total billed charges,12.23,101,,,fee schedule,101% of cms custom fee schedule,53.33,48.48,,42.664,percent of total billed charges,48.48% of total billed charges,77,70,,61.6,percent of total billed charges,70% of total billed charges,77,70,,61.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,53.33,48.48,,42.664,percent of total billed charges,48.48% of total billed charges,99,90,,79.2,percent of total billed charges,90% of total billed charges,48.48,99,
PTT,41000118,CDM,305,RC,85730,HCPCS,outpatient,,,50.5,30.30,,30.3,60,,24.24,percent of total billed charges,60% of total billed charges,24.24,48,,19.392,percent of total billed charges,48% of total billed charges,18.17,100,,,fee schedule,100% of bcbs custom fee schedule,18.17,100,,,fee schedule,100% of bcbs custom fee schedule,20.17,111,,,fee schedule,111% of bcbs custom fee schedule,25.25,50,,20.2,percent of total billed charges,50% of total billed charges,35.35,70,,28.28,percent of total billed charges,70% of total billed charges,24.48,48.48,,19.584,percent of total billed charges,48.48% of total billed charges,6.07,101,,,fee schedule,101% of cms custom fee schedule,24.48,48.48,,19.584,percent of total billed charges,48.48% of total billed charges,35.35,70,,28.28,percent of total billed charges,70% of total billed charges,35.35,70,,28.28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,24.48,48.48,,19.584,percent of total billed charges,48.48% of total billed charges,45.45,90,,36.36,percent of total billed charges,90% of total billed charges,24.48,90,
HEPATITIS C ANTIBODY,41000082,CDM,300,RC,86803,HCPCS,outpatient,,,121.5,72.90,,72.9,60,,58.32,percent of total billed charges,60% of total billed charges,58.32,48,,46.656,percent of total billed charges,48% of total billed charges,43.22,100,,,fee schedule,100% of bcbs custom fee schedule,43.22,100,,,fee schedule,100% of bcbs custom fee schedule,47.97,111,,,fee schedule,111% of bcbs custom fee schedule,60.75,50,,48.6,percent of total billed charges,50% of total billed charges,85.05,70,,68.04,percent of total billed charges,70% of total billed charges,58.9,48.48,,47.12,percent of total billed charges,48.48% of total billed charges,14.41,101,,,fee schedule,101% of cms custom fee schedule,58.9,48.48,,47.12,percent of total billed charges,48.48% of total billed charges,85.05,70,,68.04,percent of total billed charges,70% of total billed charges,85.05,70,,68.04,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,58.9,48.48,,47.12,percent of total billed charges,48.48% of total billed charges,109.35,90,,87.48,percent of total billed charges,90% of total billed charges,48.48,109.35,
VARICELLA ANTIBODY,41000049,CDM,300,RC,86787,HCPCS,outpatient,,,96,57.60,91,57.6,60,,46.08,percent of total billed charges,60% of total billed charges,46.08,48,,36.864,percent of total billed charges,48% of total billed charges,33.96,100,,,fee schedule,100% of bcbs custom fee schedule,33.96,100,,,fee schedule,100% of bcbs custom fee schedule,37.7,111,,,fee schedule,111% of bcbs custom fee schedule,48,50,,38.4,percent of total billed charges,50% of total billed charges,67.2,70,,53.76,percent of total billed charges,70% of total billed charges,46.54,48.48,,37.232,percent of total billed charges,48.48% of total billed charges,13.01,101,,,fee schedule,101% of cms custom fee schedule,46.54,48.48,,37.232,percent of total billed charges,48.48% of total billed charges,67.2,70,,53.76,percent of total billed charges,70% of total billed charges,67.2,70,,53.76,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,46.54,48.48,,37.232,percent of total billed charges,48.48% of total billed charges,86.4,90,,69.12,percent of total billed charges,90% of total billed charges,46.54,90,
MYCOPLASMA ANTIBODY,41000037,CDM,300,RC,86738,HCPCS,outpatient,,,101.5,60.90,91,60.9,60,,48.72,percent of total billed charges,60% of total billed charges,48.72,48,,38.976,percent of total billed charges,48% of total billed charges,40.12,100,,,fee schedule,100% of bcbs custom fee schedule,40.12,100,,,fee schedule,100% of bcbs custom fee schedule,44.53,111,,,fee schedule,111% of bcbs custom fee schedule,50.75,50,,40.6,percent of total billed charges,50% of total billed charges,71.05,70,,56.84,percent of total billed charges,70% of total billed charges,49.21,48.48,,39.368,percent of total billed charges,48.48% of total billed charges,13.37,101,,,fee schedule,101% of cms custom fee schedule,49.21,48.48,,39.368,percent of total billed charges,48.48% of total billed charges,71.05,70,,56.84,percent of total billed charges,70% of total billed charges,71.05,70,,56.84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,49.21,48.48,,39.368,percent of total billed charges,48.48% of total billed charges,91.35,90,,73.08,percent of total billed charges,90% of total billed charges,48.48,91.35,
RETICULOCYTE COUNT,,,300,RC,85045,HCPCS,outpatient,,,38.5,23.10,,23.1,60,,18.48,percent of total billed charges,60% of total billed charges,18.48,48,,14.784,percent of total billed charges,48% of total billed charges,12.12,100,,,fee schedule,100% of bcbs custom fee schedule,12.12,100,,,fee schedule,100% of bcbs custom fee schedule,13.45,111,,,fee schedule,111% of bcbs custom fee schedule,19.25,50,,15.4,percent of total billed charges,50% of total billed charges,26.95,70,,21.56,percent of total billed charges,70% of total billed charges,18.66,48.48,,14.928,percent of total billed charges,48.48% of total billed charges,4.03,101,,,fee schedule,101% of cms custom fee schedule,18.66,48.48,,14.928,percent of total billed charges,48.48% of total billed charges,26.95,70,,21.56,percent of total billed charges,70% of total billed charges,26.95,70,,21.56,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,18.66,48.48,,14.928,percent of total billed charges,48.48% of total billed charges,34.65,90,,27.72,percent of total billed charges,90% of total billed charges,18.66,90,
VITAMIN D 25 HYDROXY,41000126,CDM,300,RC,82306,HCPCS,outpatient,,,283.5,170.10,,170.1,60,,136.08,percent of total billed charges,60% of total billed charges,136.08,48,,108.864,percent of total billed charges,48% of total billed charges,89.66,100,,,fee schedule,100% of bcbs custom fee schedule,89.66,100,,,fee schedule,100% of bcbs custom fee schedule,99.52,111,,,fee schedule,111% of bcbs custom fee schedule,141.75,50,,113.4,percent of total billed charges,50% of total billed charges,198.45,70,,158.76,percent of total billed charges,70% of total billed charges,137.44,48.48,,109.952,percent of total billed charges,48.48% of total billed charges,29.9,101,,,fee schedule,101% of cms custom fee schedule,137.44,48.48,,109.952,percent of total billed charges,48.48% of total billed charges,198.45,70,,158.76,percent of total billed charges,70% of total billed charges,198.45,70,,158.76,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,137.44,48.48,,109.952,percent of total billed charges,48.48% of total billed charges,255.15,90,,204.12,percent of total billed charges,90% of total billed charges,48.48,255.15,
SEDIMENTATION (SED) RATE,41000107,CDM,305,RC,85651,HCPCS,outpatient,,,30.5,18.30,,18.3,60,,14.64,percent of total billed charges,60% of total billed charges,14.64,48,,11.712,percent of total billed charges,48% of total billed charges,10.75,100,,,fee schedule,100% of bcbs custom fee schedule,10.75,100,,,fee schedule,100% of bcbs custom fee schedule,11.93,111,,,fee schedule,111% of bcbs custom fee schedule,15.25,50,,12.2,percent of total billed charges,50% of total billed charges,21.35,70,,17.08,percent of total billed charges,70% of total billed charges,14.79,48.48,,11.832,percent of total billed charges,48.48% of total billed charges,4.31,101,,,fee schedule,101% of cms custom fee schedule,14.79,48.48,,11.832,percent of total billed charges,48.48% of total billed charges,21.35,70,,17.08,percent of total billed charges,70% of total billed charges,21.35,70,,17.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,14.79,48.48,,11.832,percent of total billed charges,48.48% of total billed charges,27.45,90,,21.96,percent of total billed charges,90% of total billed charges,14.79,90,
CYCLOSPORIN LEVEL,41000426,CDM,300,RC,80158,HCPCS,outpatient,,,196,117.60,,117.6,60,,94.08,percent of total billed charges,60% of total billed charges,94.08,48,,75.264,percent of total billed charges,48% of total billed charges,54.69,100,,,fee schedule,100% of bcbs custom fee schedule,54.69,100,,,fee schedule,100% of bcbs custom fee schedule,60.71,111,,,fee schedule,111% of bcbs custom fee schedule,98,50,,78.4,percent of total billed charges,50% of total billed charges,137.2,70,,109.76,percent of total billed charges,70% of total billed charges,95.02,48.48,,76.016,percent of total billed charges,48.48% of total billed charges,18.23,101,,,fee schedule,101% of cms custom fee schedule,95.02,48.48,,76.016,percent of total billed charges,48.48% of total billed charges,137.2,70,,109.76,percent of total billed charges,70% of total billed charges,137.2,70,,109.76,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,95.02,48.48,,76.016,percent of total billed charges,48.48% of total billed charges,176.4,90,,141.12,percent of total billed charges,90% of total billed charges,48.48,176.4,
SGOT,41000017,CDM,301,RC,84450,HCPCS,outpatient,,,71,42.60,,42.6,60,,34.08,percent of total billed charges,60% of total billed charges,34.08,48,,27.264,percent of total billed charges,48% of total billed charges,15.66,100,,,fee schedule,100% of bcbs custom fee schedule,15.66,100,,,fee schedule,100% of bcbs custom fee schedule,17.38,111,,,fee schedule,111% of bcbs custom fee schedule,35.5,50,,28.4,percent of total billed charges,50% of total billed charges,49.7,70,,39.76,percent of total billed charges,70% of total billed charges,34.42,48.48,,27.536,percent of total billed charges,48.48% of total billed charges,5.23,101,,,fee schedule,101% of cms custom fee schedule,34.42,48.48,,27.536,percent of total billed charges,48.48% of total billed charges,49.7,70,,39.76,percent of total billed charges,70% of total billed charges,49.7,70,,39.76,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,34.42,48.48,,27.536,percent of total billed charges,48.48% of total billed charges,63.9,90,,51.12,percent of total billed charges,90% of total billed charges,34.42,90,
CONCENTRATION OF SPECIMEN,41001207,CDM,300,RC,87015,HCPCS,outpatient,,,49.5,29.70,,29.7,60,,23.76,percent of total billed charges,60% of total billed charges,23.76,48,,19.008,percent of total billed charges,48% of total billed charges,20.23,100,,,fee schedule,100% of bcbs custom fee schedule,20.23,100,,,fee schedule,100% of bcbs custom fee schedule,22.46,111,,,fee schedule,111% of bcbs custom fee schedule,24.75,50,,19.8,percent of total billed charges,50% of total billed charges,34.65,70,,27.72,percent of total billed charges,70% of total billed charges,24,48.48,,19.2,percent of total billed charges,48.48% of total billed charges,6.75,101,,,fee schedule,101% of cms custom fee schedule,24,48.48,,19.2,percent of total billed charges,48.48% of total billed charges,34.65,70,,27.72,percent of total billed charges,70% of total billed charges,34.65,70,,27.72,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,24,48.48,,19.2,percent of total billed charges,48.48% of total billed charges,44.55,90,,35.64,percent of total billed charges,90% of total billed charges,24,90,
HISTAMINE RELEAST TEST,,,300,RC,86343,HCPCS,outpatient,,,325,195.00,,195,60,,156,percent of total billed charges,60% of total billed charges,156,48,,124.8,percent of total billed charges,48% of total billed charges,37.74,100,,,fee schedule,100% of bcbs custom fee schedule,37.74,100,,,fee schedule,100% of bcbs custom fee schedule,41.89,111,,,fee schedule,111% of bcbs custom fee schedule,162.5,50,,130,percent of total billed charges,50% of total billed charges,227.5,70,,182,percent of total billed charges,70% of total billed charges,157.56,48.48,,126.048,percent of total billed charges,48.48% of total billed charges,12.58,101,,,fee schedule,101% of cms custom fee schedule,157.56,48.48,,126.048,percent of total billed charges,48.48% of total billed charges,227.5,70,,182,percent of total billed charges,70% of total billed charges,227.5,70,,182,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,157.56,48.48,,126.048,percent of total billed charges,48.48% of total billed charges,292.5,90,,234,percent of total billed charges,90% of total billed charges,48.48,292.5,
SHIGATOXIN EACH,41001093,CDM,300,RC,87427,HCPCS,outpatient,,,83.5,50.10,91,50.1,60,,40.08,percent of total billed charges,60% of total billed charges,40.08,48,,32.064,percent of total billed charges,48% of total billed charges,36.33,100,,,fee schedule,100% of bcbs custom fee schedule,36.33,100,,,fee schedule,100% of bcbs custom fee schedule,40.33,111,,,fee schedule,111% of bcbs custom fee schedule,41.75,50,,33.4,percent of total billed charges,50% of total billed charges,58.45,70,,46.76,percent of total billed charges,70% of total billed charges,40.48,48.48,,32.384,percent of total billed charges,48.48% of total billed charges,12.1,101,,,fee schedule,101% of cms custom fee schedule,40.48,48.48,,32.384,percent of total billed charges,48.48% of total billed charges,58.45,70,,46.76,percent of total billed charges,70% of total billed charges,58.45,70,,46.76,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,40.48,48.48,,32.384,percent of total billed charges,48.48% of total billed charges,75.15,90,,60.12,percent of total billed charges,90% of total billed charges,40.48,90,
SODIUM SERUM,41000073,CDM,301,RC,84295,HCPCS,outpatient,,,68.5,41.10,,41.1,60,,32.88,percent of total billed charges,60% of total billed charges,32.88,48,,26.304,percent of total billed charges,48% of total billed charges,14.57,100,,,fee schedule,100% of bcbs custom fee schedule,14.57,100,,,fee schedule,100% of bcbs custom fee schedule,16.17,111,,,fee schedule,111% of bcbs custom fee schedule,34.25,50,,27.4,percent of total billed charges,50% of total billed charges,47.95,70,,38.36,percent of total billed charges,70% of total billed charges,33.21,48.48,,26.568,percent of total billed charges,48.48% of total billed charges,4.86,101,,,fee schedule,101% of cms custom fee schedule,33.21,48.48,,26.568,percent of total billed charges,48.48% of total billed charges,47.95,70,,38.36,percent of total billed charges,70% of total billed charges,47.95,70,,38.36,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,33.21,48.48,,26.568,percent of total billed charges,48.48% of total billed charges,61.65,90,,49.32,percent of total billed charges,90% of total billed charges,33.21,90,
CRYPTOSPORIDIUM ANTIGEN,41001128,CDM,300,RC,87328,HCPCS,outpatient,,,78,46.80,,46.8,60,,37.44,percent of total billed charges,60% of total billed charges,37.44,48,,29.952,percent of total billed charges,48% of total billed charges,36.33,100,,,fee schedule,100% of bcbs custom fee schedule,36.33,100,,,fee schedule,100% of bcbs custom fee schedule,40.33,111,,,fee schedule,111% of bcbs custom fee schedule,39,50,,31.2,percent of total billed charges,50% of total billed charges,54.6,70,,43.68,percent of total billed charges,70% of total billed charges,37.81,48.48,,30.248,percent of total billed charges,48.48% of total billed charges,13.96,101,,,fee schedule,101% of cms custom fee schedule,37.81,48.48,,30.248,percent of total billed charges,48.48% of total billed charges,54.6,70,,43.68,percent of total billed charges,70% of total billed charges,54.6,70,,43.68,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,37.81,48.48,,30.248,percent of total billed charges,48.48% of total billed charges,70.2,90,,56.16,percent of total billed charges,90% of total billed charges,37.81,90,
CMV IGG,41000267,CDM,300,RC,86644,HCPCS,outpatient,,,166.25,99.75,,99.75,60,,79.8,percent of total billed charges,60% of total billed charges,79.8,48,,63.84,percent of total billed charges,48% of total billed charges,43.6,100,,,fee schedule,100% of bcbs custom fee schedule,43.6,100,,,fee schedule,100% of bcbs custom fee schedule,48.4,111,,,fee schedule,111% of bcbs custom fee schedule,83.13,50,,66.504,percent of total billed charges,50% of total billed charges,116.38,70,,93.104,percent of total billed charges,70% of total billed charges,80.6,48.48,,64.48,percent of total billed charges,48.48% of total billed charges,14.53,101,,,fee schedule,101% of cms custom fee schedule,80.6,48.48,,64.48,percent of total billed charges,48.48% of total billed charges,116.38,70,,93.104,percent of total billed charges,70% of total billed charges,116.38,70,,93.104,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,80.6,48.48,,64.48,percent of total billed charges,48.48% of total billed charges,149.63,90,,119.704,percent of total billed charges,90% of total billed charges,48.48,149.63,
RSV,,,300,RC,87280,HCPCS,outpatient,,,93.75,56.25,,56.25,60,,45,percent of total billed charges,60% of total billed charges,45,48,,36,percent of total billed charges,48% of total billed charges,36.33,100,,,fee schedule,100% of bcbs custom fee schedule,36.33,100,,,fee schedule,100% of bcbs custom fee schedule,40.33,111,,,fee schedule,111% of bcbs custom fee schedule,46.88,50,,37.504,percent of total billed charges,50% of total billed charges,65.63,70,,52.504,percent of total billed charges,70% of total billed charges,45.45,48.48,,36.36,percent of total billed charges,48.48% of total billed charges,13.55,101,,,fee schedule,101% of cms custom fee schedule,45.45,48.48,,36.36,percent of total billed charges,48.48% of total billed charges,65.63,70,,52.504,percent of total billed charges,70% of total billed charges,65.63,70,,52.504,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,45.45,48.48,,36.36,percent of total billed charges,48.48% of total billed charges,84.38,90,,67.504,percent of total billed charges,90% of total billed charges,45.45,90,
HLA B27,41001030,CDM,300,RC,86812,HCPCS,outpatient,,,215,129.00,,129,60,,103.2,percent of total billed charges,60% of total billed charges,103.2,48,,82.56,percent of total billed charges,48% of total billed charges,78.18,100,,,fee schedule,100% of bcbs custom fee schedule,78.18,100,,,fee schedule,100% of bcbs custom fee schedule,86.78,111,,,fee schedule,111% of bcbs custom fee schedule,107.5,50,,86,percent of total billed charges,50% of total billed charges,150.5,70,,120.4,percent of total billed charges,70% of total billed charges,104.23,48.48,,83.384,percent of total billed charges,48.48% of total billed charges,26.07,101,,,fee schedule,101% of cms custom fee schedule,104.23,48.48,,83.384,percent of total billed charges,48.48% of total billed charges,150.5,70,,120.4,percent of total billed charges,70% of total billed charges,150.5,70,,120.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,104.23,48.48,,83.384,percent of total billed charges,48.48% of total billed charges,193.5,90,,154.8,percent of total billed charges,90% of total billed charges,48.48,193.5,
GIARDIA ANTIGEN,41000096,CDM,300,RC,87329,HCPCS,outpatient,,,125,75.00,,75,60,,60,percent of total billed charges,60% of total billed charges,60,48,,48,percent of total billed charges,48% of total billed charges,36.33,100,,,fee schedule,100% of bcbs custom fee schedule,36.33,100,,,fee schedule,100% of bcbs custom fee schedule,40.33,111,,,fee schedule,111% of bcbs custom fee schedule,62.5,50,,50,percent of total billed charges,50% of total billed charges,87.5,70,,70,percent of total billed charges,70% of total billed charges,60.6,48.48,,48.48,percent of total billed charges,48.48% of total billed charges,12.1,101,,,fee schedule,101% of cms custom fee schedule,60.6,48.48,,48.48,percent of total billed charges,48.48% of total billed charges,87.5,70,,70,percent of total billed charges,70% of total billed charges,87.5,70,,70,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,60.6,48.48,,48.48,percent of total billed charges,48.48% of total billed charges,112.5,90,,90,percent of total billed charges,90% of total billed charges,48.48,112.5,
STREP SCREEN RAPID,41000530,CDM,306,RC,87880,HCPCS,outpatient,,,48.5,29.10,QW,29.1,60,,23.28,percent of total billed charges,60% of total billed charges,23.28,48,,18.624,percent of total billed charges,48% of total billed charges,36.33,100,,,fee schedule,100% of bcbs custom fee schedule,36.33,100,,,fee schedule,100% of bcbs custom fee schedule,40.33,111,,,fee schedule,111% of bcbs custom fee schedule,24.25,50,,19.4,percent of total billed charges,50% of total billed charges,33.95,70,,27.16,percent of total billed charges,70% of total billed charges,23.51,48.48,,18.808,percent of total billed charges,48.48% of total billed charges,16.7,101,,,fee schedule,101% of cms custom fee schedule,23.51,48.48,,18.808,percent of total billed charges,48.48% of total billed charges,33.95,70,,27.16,percent of total billed charges,70% of total billed charges,33.95,70,,27.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,23.51,48.48,,18.808,percent of total billed charges,48.48% of total billed charges,43.65,90,,34.92,percent of total billed charges,90% of total billed charges,23.51,90,
"CRYSTAL ID, BODY FLUID",41000041,CDM,300,RC,89060,HCPCS,outpatient,,,95,57.00,,57,60,,45.6,percent of total billed charges,60% of total billed charges,45.6,48,,36.48,percent of total billed charges,48% of total billed charges,21.67,100,,,fee schedule,100% of bcbs custom fee schedule,21.67,100,,,fee schedule,100% of bcbs custom fee schedule,24.05,111,,,fee schedule,111% of bcbs custom fee schedule,47.5,50,,38,percent of total billed charges,50% of total billed charges,66.5,70,,53.2,percent of total billed charges,70% of total billed charges,46.06,48.48,,36.848,percent of total billed charges,48.48% of total billed charges,7.4,101,,,fee schedule,101% of cms custom fee schedule,46.06,48.48,,36.848,percent of total billed charges,48.48% of total billed charges,66.5,70,,53.2,percent of total billed charges,70% of total billed charges,66.5,70,,53.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,46.06,48.48,,36.848,percent of total billed charges,48.48% of total billed charges,85.5,90,,68.4,percent of total billed charges,90% of total billed charges,46.06,90,
TRIGLYCERIDES,41000304,CDM,301,RC,84478,HCPCS,outpatient,,,74,44.40,,44.4,60,,35.52,percent of total billed charges,60% of total billed charges,35.52,48,,28.416,percent of total billed charges,48% of total billed charges,17.43,100,,,fee schedule,100% of bcbs custom fee schedule,17.43,100,,,fee schedule,100% of bcbs custom fee schedule,19.35,111,,,fee schedule,111% of bcbs custom fee schedule,37,50,,29.6,percent of total billed charges,50% of total billed charges,51.8,70,,41.44,percent of total billed charges,70% of total billed charges,35.88,48.48,,28.704,percent of total billed charges,48.48% of total billed charges,5.8,101,,,fee schedule,101% of cms custom fee schedule,35.88,48.48,,28.704,percent of total billed charges,48.48% of total billed charges,51.8,70,,41.44,percent of total billed charges,70% of total billed charges,51.8,70,,41.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,35.88,48.48,,28.704,percent of total billed charges,48.48% of total billed charges,66.6,90,,53.28,percent of total billed charges,90% of total billed charges,35.88,90,
"OSMOLALITY, SERUM",41009071,CDM,300,RC,83930,HCPCS,outpatient,,,60,36.00,,36,60,,28.8,percent of total billed charges,60% of total billed charges,28.8,48,,23.04,percent of total billed charges,48% of total billed charges,20.03,100,,,fee schedule,100% of bcbs custom fee schedule,20.03,100,,,fee schedule,100% of bcbs custom fee schedule,22.23,111,,,fee schedule,111% of bcbs custom fee schedule,30,50,,24,percent of total billed charges,50% of total billed charges,42,70,,33.6,percent of total billed charges,70% of total billed charges,29.09,48.48,,23.272,percent of total billed charges,48.48% of total billed charges,6.68,101,,,fee schedule,101% of cms custom fee schedule,29.09,48.48,,23.272,percent of total billed charges,48.48% of total billed charges,42,70,,33.6,percent of total billed charges,70% of total billed charges,42,70,,33.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,29.09,48.48,,23.272,percent of total billed charges,48.48% of total billed charges,54,90,,43.2,percent of total billed charges,90% of total billed charges,29.09,90,
CYCLIC CITRULLINATED PEPTIDE,,,300,RC,86200,HCPCS,outpatient,,,175,105.00,,105,60,,84,percent of total billed charges,60% of total billed charges,84,48,,67.2,percent of total billed charges,48% of total billed charges,33.1,100,,,fee schedule,100% of bcbs custom fee schedule,33.1,100,,,fee schedule,100% of bcbs custom fee schedule,36.74,111,,,fee schedule,111% of bcbs custom fee schedule,87.5,50,,70,percent of total billed charges,50% of total billed charges,122.5,70,,98,percent of total billed charges,70% of total billed charges,84.84,48.48,,67.872,percent of total billed charges,48.48% of total billed charges,13.08,101,,,fee schedule,101% of cms custom fee schedule,84.84,48.48,,67.872,percent of total billed charges,48.48% of total billed charges,122.5,70,,98,percent of total billed charges,70% of total billed charges,122.5,70,,98,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,84.84,48.48,,67.872,percent of total billed charges,48.48% of total billed charges,157.5,90,,126,percent of total billed charges,90% of total billed charges,48.48,157.5,
ANGIOTENSIN CONVERTING ENZYME,41009066,CDM,300,RC,82164,HCPCS,outpatient,,,145,87.00,,87,60,,69.6,percent of total billed charges,60% of total billed charges,69.6,48,,55.68,percent of total billed charges,48% of total billed charges,44.2,100,,,fee schedule,100% of bcbs custom fee schedule,44.2,100,,,fee schedule,100% of bcbs custom fee schedule,49.06,111,,,fee schedule,111% of bcbs custom fee schedule,72.5,50,,58,percent of total billed charges,50% of total billed charges,101.5,70,,81.2,percent of total billed charges,70% of total billed charges,70.3,48.48,,56.24,percent of total billed charges,48.48% of total billed charges,14.75,101,,,fee schedule,101% of cms custom fee schedule,70.3,48.48,,56.24,percent of total billed charges,48.48% of total billed charges,101.5,70,,81.2,percent of total billed charges,70% of total billed charges,101.5,70,,81.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,70.3,48.48,,56.24,percent of total billed charges,48.48% of total billed charges,130.5,90,,104.4,percent of total billed charges,90% of total billed charges,48.48,130.5,
Zonisamide Level,,,300,RC,80203,HCPCS,outpatient,,,175,105.00,,105,60,,84,percent of total billed charges,60% of total billed charges,84,48,,67.2,percent of total billed charges,48% of total billed charges,33.1,100,,,fee schedule,100% of bcbs custom fee schedule,33.1,100,,,fee schedule,100% of bcbs custom fee schedule,36.74,111,,,fee schedule,111% of bcbs custom fee schedule,87.5,50,,70,percent of total billed charges,50% of total billed charges,122.5,70,,98,percent of total billed charges,70% of total billed charges,84.84,48.48,,67.872,percent of total billed charges,48.48% of total billed charges,13.38,101,,,fee schedule,101% of cms custom fee schedule,84.84,48.48,,67.872,percent of total billed charges,48.48% of total billed charges,122.5,70,,98,percent of total billed charges,70% of total billed charges,122.5,70,,98,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,84.84,48.48,,67.872,percent of total billed charges,48.48% of total billed charges,157.5,90,,126,percent of total billed charges,90% of total billed charges,48.48,157.5,
HCG QUANTITATIVE,41000141,CDM,300,RC,84702,HCPCS,outpatient,,,137.5,82.50,,82.5,60,,66,percent of total billed charges,60% of total billed charges,66,48,,52.8,percent of total billed charges,48% of total billed charges,45.58,100,,,fee schedule,100% of bcbs custom fee schedule,45.58,100,,,fee schedule,100% of bcbs custom fee schedule,50.59,111,,,fee schedule,111% of bcbs custom fee schedule,68.75,50,,55,percent of total billed charges,50% of total billed charges,96.25,70,,77,percent of total billed charges,70% of total billed charges,66.66,48.48,,53.328,percent of total billed charges,48.48% of total billed charges,15.2,101,,,fee schedule,101% of cms custom fee schedule,66.66,48.48,,53.328,percent of total billed charges,48.48% of total billed charges,96.25,70,,77,percent of total billed charges,70% of total billed charges,96.25,70,,77,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,66.66,48.48,,53.328,percent of total billed charges,48.48% of total billed charges,123.75,90,,99,percent of total billed charges,90% of total billed charges,48.48,123.75,
Ceruloplasm,41000083,CDM,300,RC,82390,HCPCS,outpatient,,,137.5,82.50,,82.5,60,,66,percent of total billed charges,60% of total billed charges,66,48,,52.8,percent of total billed charges,48% of total billed charges,32.53,100,,,fee schedule,100% of bcbs custom fee schedule,32.53,100,,,fee schedule,100% of bcbs custom fee schedule,36.11,111,,,fee schedule,111% of bcbs custom fee schedule,68.75,50,,55,percent of total billed charges,50% of total billed charges,96.25,70,,77,percent of total billed charges,70% of total billed charges,66.66,48.48,,53.328,percent of total billed charges,48.48% of total billed charges,10.85,101,,,fee schedule,101% of cms custom fee schedule,66.66,48.48,,53.328,percent of total billed charges,48.48% of total billed charges,96.25,70,,77,percent of total billed charges,70% of total billed charges,96.25,70,,77,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,66.66,48.48,,53.328,percent of total billed charges,48.48% of total billed charges,123.75,90,,99,percent of total billed charges,90% of total billed charges,48.48,123.75,
Hepatitis C RNA,41000352,CDM,300,RC,87522,HCPCS,outpatient,,,352.5,211.50,,211.5,60,,169.2,percent of total billed charges,60% of total billed charges,169.2,48,,135.36,percent of total billed charges,48% of total billed charges,129.73,100,,,fee schedule,100% of bcbs custom fee schedule,129.73,100,,,fee schedule,100% of bcbs custom fee schedule,144,111,,,fee schedule,111% of bcbs custom fee schedule,176.25,50,,141,percent of total billed charges,50% of total billed charges,246.75,70,,197.4,percent of total billed charges,70% of total billed charges,170.89,48.48,,136.712,percent of total billed charges,48.48% of total billed charges,43.27,101,,,fee schedule,101% of cms custom fee schedule,170.89,48.48,,136.712,percent of total billed charges,48.48% of total billed charges,246.75,70,,197.4,percent of total billed charges,70% of total billed charges,246.75,70,,197.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,170.89,48.48,,136.712,percent of total billed charges,48.48% of total billed charges,317.25,90,,253.8,percent of total billed charges,90% of total billed charges,48.48,317.25,
URIC ACID,41000001,CDM,301,RC,84550,HCPCS,outpatient,,,73.5,44.10,,44.1,60,,35.28,percent of total billed charges,60% of total billed charges,35.28,48,,28.224,percent of total billed charges,48% of total billed charges,13.69,100,,,fee schedule,100% of bcbs custom fee schedule,13.69,100,,,fee schedule,100% of bcbs custom fee schedule,15.2,111,,,fee schedule,111% of bcbs custom fee schedule,36.75,50,,29.4,percent of total billed charges,50% of total billed charges,51.45,70,,41.16,percent of total billed charges,70% of total billed charges,35.63,48.48,,28.504,percent of total billed charges,48.48% of total billed charges,4.57,101,,,fee schedule,101% of cms custom fee schedule,35.63,48.48,,28.504,percent of total billed charges,48.48% of total billed charges,51.45,70,,41.16,percent of total billed charges,70% of total billed charges,51.45,70,,41.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,35.63,48.48,,28.504,percent of total billed charges,48.48% of total billed charges,66.15,90,,52.92,percent of total billed charges,90% of total billed charges,35.63,90,
"CANNABINOIDS, NATURAL CONFIRMATION",,,300,RC,80349,HCPCS,outpatient,,,62.5,37.50,,37.5,60,,30,percent of total billed charges,60% of total billed charges,30,48,,24,percent of total billed charges,48% of total billed charges,16.9,100,,,fee schedule,100% of bcbs custom fee schedule,16.9,100,,,fee schedule,100% of bcbs custom fee schedule,18.76,111,,,fee schedule,111% of bcbs custom fee schedule,31.25,50,,25,percent of total billed charges,50% of total billed charges,43.75,70,,35,percent of total billed charges,70% of total billed charges,30.3,48.48,,24.24,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,30.3,48.48,,24.24,percent of total billed charges,48.48% of total billed charges,43.75,70,,35,percent of total billed charges,70% of total billed charges,43.75,70,,35,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,30.3,48.48,,24.24,percent of total billed charges,48.48% of total billed charges,56.25,90,,45,percent of total billed charges,90% of total billed charges,30.3,90,
"COMPLEMENT ANTIGEN, EACH COMPONENT",41000128,CDM,300,RC,86160,HCPCS,outpatient,,,175,105.00,91,105,60,,84,percent of total billed charges,60% of total billed charges,84,48,,67.2,percent of total billed charges,48% of total billed charges,36.37,100,,,fee schedule,100% of bcbs custom fee schedule,36.37,100,,,fee schedule,100% of bcbs custom fee schedule,40.37,111,,,fee schedule,111% of bcbs custom fee schedule,87.5,50,,70,percent of total billed charges,50% of total billed charges,122.5,70,,98,percent of total billed charges,70% of total billed charges,84.84,48.48,,67.872,percent of total billed charges,48.48% of total billed charges,12.12,101,,,fee schedule,101% of cms custom fee schedule,84.84,48.48,,67.872,percent of total billed charges,48.48% of total billed charges,122.5,70,,98,percent of total billed charges,70% of total billed charges,122.5,70,,98,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,84.84,48.48,,67.872,percent of total billed charges,48.48% of total billed charges,157.5,90,,126,percent of total billed charges,90% of total billed charges,48.48,157.5,
"COMPLEMENT FUNCTIONAL ACTIVITY, EACH",41000160,CDM,300,RC,86161,HCPCS,outpatient,,,150,90.00,,90,60,,72,percent of total billed charges,60% of total billed charges,72,48,,57.6,percent of total billed charges,48% of total billed charges,36.37,100,,,fee schedule,100% of bcbs custom fee schedule,36.37,100,,,fee schedule,100% of bcbs custom fee schedule,40.37,111,,,fee schedule,111% of bcbs custom fee schedule,75,50,,60,percent of total billed charges,50% of total billed charges,105,70,,84,percent of total billed charges,70% of total billed charges,72.72,48.48,,58.176,percent of total billed charges,48.48% of total billed charges,12.12,101,,,fee schedule,101% of cms custom fee schedule,72.72,48.48,,58.176,percent of total billed charges,48.48% of total billed charges,105,70,,84,percent of total billed charges,70% of total billed charges,105,70,,84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,72.72,48.48,,58.176,percent of total billed charges,48.48% of total billed charges,135,90,,108,percent of total billed charges,90% of total billed charges,48.48,135,
COMPLEMENT TOTAL CH50,41000159,CDM,300,RC,86162,HCPCS,outpatient,,,192.5,115.50,,115.5,60,,92.4,percent of total billed charges,60% of total billed charges,92.4,48,,73.92,percent of total billed charges,48% of total billed charges,57.77,100,,,fee schedule,100% of bcbs custom fee schedule,57.77,100,,,fee schedule,100% of bcbs custom fee schedule,64.12,111,,,fee schedule,111% of bcbs custom fee schedule,96.25,50,,77,percent of total billed charges,50% of total billed charges,134.75,70,,107.8,percent of total billed charges,70% of total billed charges,93.32,48.48,,74.656,percent of total billed charges,48.48% of total billed charges,20.52,101,,,fee schedule,101% of cms custom fee schedule,93.32,48.48,,74.656,percent of total billed charges,48.48% of total billed charges,134.75,70,,107.8,percent of total billed charges,70% of total billed charges,134.75,70,,107.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,93.32,48.48,,74.656,percent of total billed charges,48.48% of total billed charges,173.25,90,,138.6,percent of total billed charges,90% of total billed charges,48.48,173.25,
BENZODIAZEPINES CONFIRMATION,,,300,RC,80346,HCPCS,outpatient,,,67,40.20,,40.2,60,,32.16,percent of total billed charges,60% of total billed charges,32.16,48,,25.728,percent of total billed charges,48% of total billed charges,16.79,100,,,fee schedule,100% of bcbs custom fee schedule,16.79,100,,,fee schedule,100% of bcbs custom fee schedule,18.64,111,,,fee schedule,111% of bcbs custom fee schedule,33.5,50,,26.8,percent of total billed charges,50% of total billed charges,46.9,70,,37.52,percent of total billed charges,70% of total billed charges,32.48,48.48,,25.984,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,32.48,48.48,,25.984,percent of total billed charges,48.48% of total billed charges,46.9,70,,37.52,percent of total billed charges,70% of total billed charges,46.9,70,,37.52,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,32.48,48.48,,25.984,percent of total billed charges,48.48% of total billed charges,60.3,90,,48.24,percent of total billed charges,90% of total billed charges,32.48,90,
Aquaporin-4 IgG,41000204,CDM,300,RC,86255,HCPCS,outpatient,,,675,405.00,91,405,60,,324,percent of total billed charges,60% of total billed charges,324,48,,259.2,percent of total billed charges,48% of total billed charges,34.38,100,,,fee schedule,100% of bcbs custom fee schedule,34.38,100,,,fee schedule,100% of bcbs custom fee schedule,38.16,111,,,fee schedule,111% of bcbs custom fee schedule,337.5,50,,270,percent of total billed charges,50% of total billed charges,472.5,70,,378,percent of total billed charges,70% of total billed charges,327.24,48.48,,261.792,percent of total billed charges,48.48% of total billed charges,12.17,101,,,fee schedule,101% of cms custom fee schedule,327.24,48.48,,261.792,percent of total billed charges,48.48% of total billed charges,472.5,70,,378,percent of total billed charges,70% of total billed charges,472.5,70,,378,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,327.24,48.48,,261.792,percent of total billed charges,48.48% of total billed charges,607.5,90,,486,percent of total billed charges,90% of total billed charges,48.48,607.5,
HEPATITIS C GENOTYPING,41001045,CDM,300,RC,87902,HCPCS,outpatient,,,600,360.00,,360,60,,288,percent of total billed charges,60% of total billed charges,288,48,,230.4,percent of total billed charges,48% of total billed charges,779.73,100,,,fee schedule,100% of bcbs custom fee schedule,779.73,100,,,fee schedule,100% of bcbs custom fee schedule,865.5,111,,,fee schedule,111% of bcbs custom fee schedule,300,50,,240,percent of total billed charges,50% of total billed charges,420,70,,336,percent of total billed charges,70% of total billed charges,290.88,48.48,,232.704,percent of total billed charges,48.48% of total billed charges,260.02,101,,,fee schedule,101% of cms custom fee schedule,290.88,48.48,,232.704,percent of total billed charges,48.48% of total billed charges,420,70,,336,percent of total billed charges,70% of total billed charges,420,70,,336,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,290.88,48.48,,232.704,percent of total billed charges,48.48% of total billed charges,540,90,,432,percent of total billed charges,90% of total billed charges,48.48,540,
WBC AUTOMATED,41000397,CDM,305,RC,85048,HCPCS,outpatient,,,32.5,19.50,,19.5,60,,15.6,percent of total billed charges,60% of total billed charges,15.6,48,,12.48,percent of total billed charges,48% of total billed charges,7.69,100,,,fee schedule,100% of bcbs custom fee schedule,7.69,100,,,fee schedule,100% of bcbs custom fee schedule,8.54,111,,,fee schedule,111% of bcbs custom fee schedule,16.25,50,,13,percent of total billed charges,50% of total billed charges,22.75,70,,18.2,percent of total billed charges,70% of total billed charges,15.76,48.48,,12.608,percent of total billed charges,48.48% of total billed charges,2.57,101,,,fee schedule,101% of cms custom fee schedule,15.76,48.48,,12.608,percent of total billed charges,48.48% of total billed charges,22.75,70,,18.2,percent of total billed charges,70% of total billed charges,22.75,70,,18.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,15.76,48.48,,12.608,percent of total billed charges,48.48% of total billed charges,29.25,90,,23.4,percent of total billed charges,90% of total billed charges,15.76,90,
PHENCYCLIDINE CONFIRMATION,41000433,CDM,300,RC,83992,HCPCS,outpatient,,,109,65.40,,65.4,60,,52.32,percent of total billed charges,60% of total billed charges,52.32,48,,41.856,percent of total billed charges,48% of total billed charges,44.53,100,,,fee schedule,100% of bcbs custom fee schedule,44.53,100,,,fee schedule,100% of bcbs custom fee schedule,49.43,111,,,fee schedule,111% of bcbs custom fee schedule,54.5,50,,43.6,percent of total billed charges,50% of total billed charges,76.3,70,,61.04,percent of total billed charges,70% of total billed charges,52.84,48.48,,42.272,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,52.84,48.48,,42.272,percent of total billed charges,48.48% of total billed charges,76.3,70,,61.04,percent of total billed charges,70% of total billed charges,76.3,70,,61.04,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,52.84,48.48,,42.272,percent of total billed charges,48.48% of total billed charges,98.1,90,,78.48,percent of total billed charges,90% of total billed charges,48.48,98.1,
WET PREP,41000451,CDM,306,RC,87210,HCPCS,outpatient,,,37.5,22.50,,22.5,60,,18,percent of total billed charges,60% of total billed charges,18,48,,14.4,percent of total billed charges,48% of total billed charges,12.91,100,,,fee schedule,100% of bcbs custom fee schedule,12.91,100,,,fee schedule,100% of bcbs custom fee schedule,14.33,111,,,fee schedule,111% of bcbs custom fee schedule,18.75,50,,15,percent of total billed charges,50% of total billed charges,26.25,70,,21,percent of total billed charges,70% of total billed charges,18.18,48.48,,14.544,percent of total billed charges,48.48% of total billed charges,5.88,101,,,fee schedule,101% of cms custom fee schedule,18.18,48.48,,14.544,percent of total billed charges,48.48% of total billed charges,26.25,70,,21,percent of total billed charges,70% of total billed charges,26.25,70,,21,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,18.18,48.48,,14.544,percent of total billed charges,48.48% of total billed charges,33.75,90,,27,percent of total billed charges,90% of total billed charges,18.18,90,
LEVETIRACETAM LEVEL,,,300,RC,80177,HCPCS,outpatient,,,137.5,82.50,,82.5,60,,66,percent of total billed charges,60% of total billed charges,66,48,,52.8,percent of total billed charges,48% of total billed charges,33.1,100,,,fee schedule,100% of bcbs custom fee schedule,33.1,100,,,fee schedule,100% of bcbs custom fee schedule,36.74,111,,,fee schedule,111% of bcbs custom fee schedule,68.75,50,,55,percent of total billed charges,50% of total billed charges,96.25,70,,77,percent of total billed charges,70% of total billed charges,66.66,48.48,,53.328,percent of total billed charges,48.48% of total billed charges,13.38,101,,,fee schedule,101% of cms custom fee schedule,66.66,48.48,,53.328,percent of total billed charges,48.48% of total billed charges,96.25,70,,77,percent of total billed charges,70% of total billed charges,96.25,70,,77,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,66.66,48.48,,53.328,percent of total billed charges,48.48% of total billed charges,123.75,90,,99,percent of total billed charges,90% of total billed charges,48.48,123.75,
"FUNGAL CULTURE, OTHER",41000522,CDM,306,RC,87102,HCPCS,outpatient,,,63.5,38.10,,38.1,60,,30.48,percent of total billed charges,60% of total billed charges,30.48,48,,24.384,percent of total billed charges,48% of total billed charges,25.45,100,,,fee schedule,100% of bcbs custom fee schedule,25.45,100,,,fee schedule,100% of bcbs custom fee schedule,28.25,111,,,fee schedule,111% of bcbs custom fee schedule,31.75,50,,25.4,percent of total billed charges,50% of total billed charges,44.45,70,,35.56,percent of total billed charges,70% of total billed charges,30.78,48.48,,24.624,percent of total billed charges,48.48% of total billed charges,8.49,101,,,fee schedule,101% of cms custom fee schedule,30.78,48.48,,24.624,percent of total billed charges,48.48% of total billed charges,44.45,70,,35.56,percent of total billed charges,70% of total billed charges,44.45,70,,35.56,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,30.78,48.48,,24.624,percent of total billed charges,48.48% of total billed charges,57.15,90,,45.72,percent of total billed charges,90% of total billed charges,30.78,90,
MUMPS IGG or IGM,41000085,CDM,300,RC,86735,HCPCS,outpatient,,,89,53.40,91,53.4,60,,42.72,percent of total billed charges,60% of total billed charges,42.72,48,,34.176,percent of total billed charges,48% of total billed charges,39.52,100,,,fee schedule,100% of bcbs custom fee schedule,39.52,100,,,fee schedule,100% of bcbs custom fee schedule,43.87,111,,,fee schedule,111% of bcbs custom fee schedule,44.5,50,,35.6,percent of total billed charges,50% of total billed charges,62.3,70,,49.84,percent of total billed charges,70% of total billed charges,43.15,48.48,,34.52,percent of total billed charges,48.48% of total billed charges,13.18,101,,,fee schedule,101% of cms custom fee schedule,43.15,48.48,,34.52,percent of total billed charges,48.48% of total billed charges,62.3,70,,49.84,percent of total billed charges,70% of total billed charges,62.3,70,,49.84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,43.15,48.48,,34.52,percent of total billed charges,48.48% of total billed charges,80.1,90,,64.08,percent of total billed charges,90% of total billed charges,43.15,90,
GLUCOSE BLOOD REAGNT STRP,41000469,CDM,301,RC,82948,HCPCS,outpatient,,,24,14.40,,14.4,60,,11.52,percent of total billed charges,60% of total billed charges,11.52,48,,9.216,percent of total billed charges,48% of total billed charges,9.6,100,,,fee schedule,100% of bcbs custom fee schedule,9.6,100,,,fee schedule,100% of bcbs custom fee schedule,10.66,111,,,fee schedule,111% of bcbs custom fee schedule,12,50,,9.6,percent of total billed charges,50% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,5.09,101,,,fee schedule,101% of cms custom fee schedule,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,21.6,90,,17.28,percent of total billed charges,90% of total billed charges,11.64,90,
MEASELS RUBEOLA IGG,41000056,CDM,300,RC,86765,HCPCS,outpatient,,,118.5,71.10,,71.1,60,,56.88,percent of total billed charges,60% of total billed charges,56.88,48,,45.504,percent of total billed charges,48% of total billed charges,39.02,100,,,fee schedule,100% of bcbs custom fee schedule,39.02,100,,,fee schedule,100% of bcbs custom fee schedule,43.31,111,,,fee schedule,111% of bcbs custom fee schedule,59.25,50,,47.4,percent of total billed charges,50% of total billed charges,82.95,70,,66.36,percent of total billed charges,70% of total billed charges,57.45,48.48,,45.96,percent of total billed charges,48.48% of total billed charges,13.01,101,,,fee schedule,101% of cms custom fee schedule,57.45,48.48,,45.96,percent of total billed charges,48.48% of total billed charges,82.95,70,,66.36,percent of total billed charges,70% of total billed charges,82.95,70,,66.36,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,57.45,48.48,,45.96,percent of total billed charges,48.48% of total billed charges,106.65,90,,85.32,percent of total billed charges,90% of total billed charges,48.48,106.65,
VENIPUNCTURE,41001161,CDM,300,RC,36415,HCPCS,outpatient,,,24.5,14.70,,14.7,60,,11.76,percent of total billed charges,60% of total billed charges,11.76,48,,9.408,percent of total billed charges,48% of total billed charges,6.6,100,,,fee schedule,100% of bcbs custom fee schedule,6.6,100,,,fee schedule,100% of bcbs custom fee schedule,7.33,111,,,fee schedule,111% of bcbs custom fee schedule,12.25,50,,9.8,percent of total billed charges,50% of total billed charges,17.15,70,,13.72,percent of total billed charges,70% of total billed charges,11.88,48.48,,9.504,percent of total billed charges,48.48% of total billed charges,8.92,101,,,fee schedule,101% of cms custom fee schedule,11.88,48.48,,9.504,percent of total billed charges,48.48% of total billed charges,17.15,70,,13.72,percent of total billed charges,70% of total billed charges,17.15,70,,13.72,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,11.88,48.48,,9.504,percent of total billed charges,48.48% of total billed charges,22.05,90,,17.64,percent of total billed charges,90% of total billed charges,11.88,90,
RUBELLA IGG,41000283,CDM,300,RC,86762,HCPCS,outpatient,,,102.5,61.50,,61.5,60,,49.2,percent of total billed charges,60% of total billed charges,49.2,48,,39.36,percent of total billed charges,48% of total billed charges,43.6,100,,,fee schedule,100% of bcbs custom fee schedule,43.6,100,,,fee schedule,100% of bcbs custom fee schedule,48.4,111,,,fee schedule,111% of bcbs custom fee schedule,51.25,50,,41,percent of total billed charges,50% of total billed charges,71.75,70,,57.4,percent of total billed charges,70% of total billed charges,49.69,48.48,,39.752,percent of total billed charges,48.48% of total billed charges,14.53,101,,,fee schedule,101% of cms custom fee schedule,49.69,48.48,,39.752,percent of total billed charges,48.48% of total billed charges,71.75,70,,57.4,percent of total billed charges,70% of total billed charges,71.75,70,,57.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,49.69,48.48,,39.752,percent of total billed charges,48.48% of total billed charges,92.25,90,,73.8,percent of total billed charges,90% of total billed charges,48.48,92.25,
Insulin Autoantibody,41000071,CDM,300,RC,86337,HCPCS,outpatient,,,225,135.00,,135,60,,108,percent of total billed charges,60% of total billed charges,108,48,,86.4,percent of total billed charges,48% of total billed charges,31.67,100,,,fee schedule,100% of bcbs custom fee schedule,31.67,100,,,fee schedule,100% of bcbs custom fee schedule,35.15,111,,,fee schedule,111% of bcbs custom fee schedule,112.5,50,,90,percent of total billed charges,50% of total billed charges,157.5,70,,126,percent of total billed charges,70% of total billed charges,109.08,48.48,,87.264,percent of total billed charges,48.48% of total billed charges,21.62,101,,,fee schedule,101% of cms custom fee schedule,109.08,48.48,,87.264,percent of total billed charges,48.48% of total billed charges,157.5,70,,126,percent of total billed charges,70% of total billed charges,157.5,70,,126,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,109.08,48.48,,87.264,percent of total billed charges,48.48% of total billed charges,202.5,90,,162,percent of total billed charges,90% of total billed charges,48.48,202.5,
"PHOSPHATE, URINE",41000171,CDM,300,RC,84105,HCPCS,outpatient,,,73.75,44.25,,44.25,60,,35.4,percent of total billed charges,60% of total billed charges,35.4,48,,28.32,percent of total billed charges,48% of total billed charges,15.67,100,,,fee schedule,100% of bcbs custom fee schedule,15.67,100,,,fee schedule,100% of bcbs custom fee schedule,17.39,111,,,fee schedule,111% of bcbs custom fee schedule,36.88,50,,29.504,percent of total billed charges,50% of total billed charges,51.63,70,,41.304,percent of total billed charges,70% of total billed charges,35.75,48.48,,28.6,percent of total billed charges,48.48% of total billed charges,5.84,101,,,fee schedule,101% of cms custom fee schedule,35.75,48.48,,28.6,percent of total billed charges,48.48% of total billed charges,51.63,70,,41.304,percent of total billed charges,70% of total billed charges,51.63,70,,41.304,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,35.75,48.48,,28.6,percent of total billed charges,48.48% of total billed charges,66.38,90,,53.104,percent of total billed charges,90% of total billed charges,35.75,90,
BLOOD TYPING ABO,41040209,CDM,300,RC,86900,HCPCS,outpatient,,,105,63.00,,63,60,,50.4,percent of total billed charges,60% of total billed charges,50.4,48,,40.32,percent of total billed charges,48% of total billed charges,9.03,100,,,fee schedule,100% of bcbs custom fee schedule,9.03,100,,,fee schedule,100% of bcbs custom fee schedule,10.02,111,,,fee schedule,111% of bcbs custom fee schedule,52.5,50,,42,percent of total billed charges,50% of total billed charges,73.5,70,,58.8,percent of total billed charges,70% of total billed charges,50.9,48.48,,40.72,percent of total billed charges,48.48% of total billed charges,3.02,101,,,fee schedule,101% of cms custom fee schedule,50.9,48.48,,40.72,percent of total billed charges,48.48% of total billed charges,73.5,70,,58.8,percent of total billed charges,70% of total billed charges,73.5,70,,58.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,50.9,48.48,,40.72,percent of total billed charges,48.48% of total billed charges,94.5,90,,75.6,percent of total billed charges,90% of total billed charges,48.48,94.5,
"CALCIUM, URINE TIMED",41009056,CDM,300,RC,82340,HCPCS,outpatient,,,72.5,43.50,,43.5,60,,34.8,percent of total billed charges,60% of total billed charges,34.8,48,,27.84,percent of total billed charges,48% of total billed charges,18.27,100,,,fee schedule,100% of bcbs custom fee schedule,18.27,100,,,fee schedule,100% of bcbs custom fee schedule,20.28,111,,,fee schedule,111% of bcbs custom fee schedule,36.25,50,,29,percent of total billed charges,50% of total billed charges,50.75,70,,40.6,percent of total billed charges,70% of total billed charges,35.15,48.48,,28.12,percent of total billed charges,48.48% of total billed charges,6.09,101,,,fee schedule,101% of cms custom fee schedule,35.15,48.48,,28.12,percent of total billed charges,48.48% of total billed charges,50.75,70,,40.6,percent of total billed charges,70% of total billed charges,50.75,70,,40.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,35.15,48.48,,28.12,percent of total billed charges,48.48% of total billed charges,65.25,90,,52.2,percent of total billed charges,90% of total billed charges,35.15,90,
CROSSMATCH EACH,41040215,CDM,300,RC,86920,HCPCS,outpatient,,,96,57.60,,57.6,60,,46.08,percent of total billed charges,60% of total billed charges,46.08,48,,36.864,percent of total billed charges,48% of total billed charges,28.38,100,,,fee schedule,100% of bcbs custom fee schedule,28.38,100,,,fee schedule,100% of bcbs custom fee schedule,31.5,111,,,fee schedule,111% of bcbs custom fee schedule,48,50,,38.4,percent of total billed charges,50% of total billed charges,67.2,70,,53.76,percent of total billed charges,70% of total billed charges,46.54,48.48,,37.232,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,46.54,48.48,,37.232,percent of total billed charges,48.48% of total billed charges,67.2,70,,53.76,percent of total billed charges,70% of total billed charges,67.2,70,,53.76,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,46.54,48.48,,37.232,percent of total billed charges,48.48% of total billed charges,86.4,90,,69.12,percent of total billed charges,90% of total billed charges,46.54,90,
"CREATININE, URINE",41001006,CDM,300,RC,82570,HCPCS,outpatient,,,38.75,23.25,,23.25,60,,18.6,percent of total billed charges,60% of total billed charges,18.6,48,,14.88,percent of total billed charges,48% of total billed charges,15.67,100,,,fee schedule,100% of bcbs custom fee schedule,15.67,100,,,fee schedule,100% of bcbs custom fee schedule,17.39,111,,,fee schedule,111% of bcbs custom fee schedule,19.38,50,,15.504,percent of total billed charges,50% of total billed charges,27.13,70,,21.704,percent of total billed charges,70% of total billed charges,18.79,48.48,,15.032,percent of total billed charges,48.48% of total billed charges,5.23,101,,,fee schedule,101% of cms custom fee schedule,18.79,48.48,,15.032,percent of total billed charges,48.48% of total billed charges,27.13,70,,21.704,percent of total billed charges,70% of total billed charges,27.13,70,,21.704,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,18.79,48.48,,15.032,percent of total billed charges,48.48% of total billed charges,34.88,90,,27.904,percent of total billed charges,90% of total billed charges,18.79,90,
"Copper, 24 hr Urine",41000298,CDM,300,RC,82525,HCPCS,outpatient,,,150,90.00,,90,60,,72,percent of total billed charges,60% of total billed charges,72,48,,57.6,percent of total billed charges,48% of total billed charges,37.59,100,,,fee schedule,100% of bcbs custom fee schedule,37.59,100,,,fee schedule,100% of bcbs custom fee schedule,41.72,111,,,fee schedule,111% of bcbs custom fee schedule,75,50,,60,percent of total billed charges,50% of total billed charges,105,70,,84,percent of total billed charges,70% of total billed charges,72.72,48.48,,58.176,percent of total billed charges,48.48% of total billed charges,12.53,101,,,fee schedule,101% of cms custom fee schedule,72.72,48.48,,58.176,percent of total billed charges,48.48% of total billed charges,105,70,,84,percent of total billed charges,70% of total billed charges,105,70,,84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,72.72,48.48,,58.176,percent of total billed charges,48.48% of total billed charges,135,90,,108,percent of total billed charges,90% of total billed charges,48.48,135,
"FUNGAL CULTURE, BLOOD",41009152,CDM,300,RC,87103,HCPCS,outpatient,,,64.5,38.70,,38.7,60,,30.96,percent of total billed charges,60% of total billed charges,30.96,48,,24.768,percent of total billed charges,48% of total billed charges,25.65,100,,,fee schedule,100% of bcbs custom fee schedule,25.65,100,,,fee schedule,100% of bcbs custom fee schedule,28.47,111,,,fee schedule,111% of bcbs custom fee schedule,32.25,50,,25.8,percent of total billed charges,50% of total billed charges,45.15,70,,36.12,percent of total billed charges,70% of total billed charges,31.27,48.48,,25.016,percent of total billed charges,48.48% of total billed charges,20.66,101,,,fee schedule,101% of cms custom fee schedule,31.27,48.48,,25.016,percent of total billed charges,48.48% of total billed charges,45.15,70,,36.12,percent of total billed charges,70% of total billed charges,45.15,70,,36.12,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,31.27,48.48,,25.016,percent of total billed charges,48.48% of total billed charges,58.05,90,,46.44,percent of total billed charges,90% of total billed charges,31.27,90,
INDIRECT COOMBS AB TITER,41009096,CDM,302,RC,86886,HCPCS,outpatient,,,93.75,56.25,,56.25,60,,45,percent of total billed charges,60% of total billed charges,45,48,,36,percent of total billed charges,48% of total billed charges,15.67,100,,,fee schedule,100% of bcbs custom fee schedule,15.67,100,,,fee schedule,100% of bcbs custom fee schedule,17.39,111,,,fee schedule,111% of bcbs custom fee schedule,46.88,50,,37.504,percent of total billed charges,50% of total billed charges,65.63,70,,52.504,percent of total billed charges,70% of total billed charges,45.45,48.48,,36.36,percent of total billed charges,48.48% of total billed charges,5.23,101,,,fee schedule,101% of cms custom fee schedule,45.45,48.48,,36.36,percent of total billed charges,48.48% of total billed charges,65.63,70,,52.504,percent of total billed charges,70% of total billed charges,65.63,70,,52.504,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,45.45,48.48,,36.36,percent of total billed charges,48.48% of total billed charges,84.38,90,,67.504,percent of total billed charges,90% of total billed charges,45.45,90,
MICROSOMIAL / TPO ANTIBODY,41000154,CDM,300,RC,86376,HCPCS,outpatient,,,114.5,68.70,,68.7,60,,54.96,percent of total billed charges,60% of total billed charges,54.96,48,,43.968,percent of total billed charges,48% of total billed charges,44.07,100,,,fee schedule,100% of bcbs custom fee schedule,44.07,100,,,fee schedule,100% of bcbs custom fee schedule,48.92,111,,,fee schedule,111% of bcbs custom fee schedule,57.25,50,,45.8,percent of total billed charges,50% of total billed charges,80.15,70,,64.12,percent of total billed charges,70% of total billed charges,55.51,48.48,,44.408,percent of total billed charges,48.48% of total billed charges,14.7,101,,,fee schedule,101% of cms custom fee schedule,55.51,48.48,,44.408,percent of total billed charges,48.48% of total billed charges,80.15,70,,64.12,percent of total billed charges,70% of total billed charges,80.15,70,,64.12,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,55.51,48.48,,44.408,percent of total billed charges,48.48% of total billed charges,103.05,90,,82.44,percent of total billed charges,90% of total billed charges,48.48,103.05,
Fecal Blood Screen Immunoassay,41001204,CDM,300,RC,G0328,HCPCS,outpatient,,,125,75.00,,75,60,,60,percent of total billed charges,60% of total billed charges,60,48,,48,percent of total billed charges,48% of total billed charges,35.93,100,,,fee schedule,100% of bcbs custom fee schedule,35.93,100,,,fee schedule,100% of bcbs custom fee schedule,39.88,111,,,fee schedule,111% of bcbs custom fee schedule,62.5,50,,50,percent of total billed charges,50% of total billed charges,87.5,70,,70,percent of total billed charges,70% of total billed charges,60.6,48.48,,48.48,percent of total billed charges,48.48% of total billed charges,18.23,101,,,fee schedule,101% of cms custom fee schedule,60.6,48.48,,48.48,percent of total billed charges,48.48% of total billed charges,87.5,70,,70,percent of total billed charges,70% of total billed charges,87.5,70,,70,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,60.6,48.48,,48.48,percent of total billed charges,48.48% of total billed charges,112.5,90,,90,percent of total billed charges,90% of total billed charges,48.48,112.5,
T3 REVERSE,41001056,CDM,300,RC,84482,HCPCS,outpatient,,,144,86.40,,86.4,60,,69.12,percent of total billed charges,60% of total billed charges,69.12,48,,55.296,percent of total billed charges,48% of total billed charges,14.09,100,,,fee schedule,100% of bcbs custom fee schedule,14.09,100,,,fee schedule,100% of bcbs custom fee schedule,15.64,111,,,fee schedule,111% of bcbs custom fee schedule,72,50,,57.6,percent of total billed charges,50% of total billed charges,100.8,70,,80.64,percent of total billed charges,70% of total billed charges,69.81,48.48,,55.848,percent of total billed charges,48.48% of total billed charges,15.92,101,,,fee schedule,101% of cms custom fee schedule,69.81,48.48,,55.848,percent of total billed charges,48.48% of total billed charges,100.8,70,,80.64,percent of total billed charges,70% of total billed charges,100.8,70,,80.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,69.81,48.48,,55.848,percent of total billed charges,48.48% of total billed charges,129.6,90,,103.68,percent of total billed charges,90% of total billed charges,48.48,129.6,
"Chloride, Urine",41000401,CDM,300,RC,82436,HCPCS,outpatient,,,46.25,27.75,,27.75,60,,22.2,percent of total billed charges,60% of total billed charges,22.2,48,,17.76,percent of total billed charges,48% of total billed charges,15.22,100,,,fee schedule,100% of bcbs custom fee schedule,15.22,100,,,fee schedule,100% of bcbs custom fee schedule,16.89,111,,,fee schedule,111% of bcbs custom fee schedule,23.13,50,,18.504,percent of total billed charges,50% of total billed charges,32.38,70,,25.904,percent of total billed charges,70% of total billed charges,22.42,48.48,,17.936,percent of total billed charges,48.48% of total billed charges,5.81,101,,,fee schedule,101% of cms custom fee schedule,22.42,48.48,,17.936,percent of total billed charges,48.48% of total billed charges,32.38,70,,25.904,percent of total billed charges,70% of total billed charges,32.38,70,,25.904,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,22.42,48.48,,17.936,percent of total billed charges,48.48% of total billed charges,41.63,90,,33.304,percent of total billed charges,90% of total billed charges,22.42,90,
"CALCIUM, IONIZED",41009163,CDM,300,RC,82330,HCPCS,outpatient,,,122.5,73.50,,73.5,60,,58.8,percent of total billed charges,60% of total billed charges,58.8,48,,47.04,percent of total billed charges,48% of total billed charges,41.39,100,,,fee schedule,100% of bcbs custom fee schedule,41.39,100,,,fee schedule,100% of bcbs custom fee schedule,45.94,111,,,fee schedule,111% of bcbs custom fee schedule,61.25,50,,49,percent of total billed charges,50% of total billed charges,85.75,70,,68.6,percent of total billed charges,70% of total billed charges,59.39,48.48,,47.512,percent of total billed charges,48.48% of total billed charges,13.82,101,,,fee schedule,101% of cms custom fee schedule,59.39,48.48,,47.512,percent of total billed charges,48.48% of total billed charges,85.75,70,,68.6,percent of total billed charges,70% of total billed charges,85.75,70,,68.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,59.39,48.48,,47.512,percent of total billed charges,48.48% of total billed charges,110.25,90,,88.2,percent of total billed charges,90% of total billed charges,48.48,110.25,
ANTI SMITH / SM,41000193,CDM,300,RC,86235,HCPCS,outpatient,,,128.5,77.10,91,77.1,60,,61.68,percent of total billed charges,60% of total billed charges,61.68,48,,49.344,percent of total billed charges,48% of total billed charges,35.24,100,,,fee schedule,100% of bcbs custom fee schedule,35.24,100,,,fee schedule,100% of bcbs custom fee schedule,39.12,111,,,fee schedule,111% of bcbs custom fee schedule,64.25,50,,51.4,percent of total billed charges,50% of total billed charges,89.95,70,,71.96,percent of total billed charges,70% of total billed charges,62.3,48.48,,49.84,percent of total billed charges,48.48% of total billed charges,18.11,101,,,fee schedule,101% of cms custom fee schedule,62.3,48.48,,49.84,percent of total billed charges,48.48% of total billed charges,89.95,70,,71.96,percent of total billed charges,70% of total billed charges,89.95,70,,71.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,62.3,48.48,,49.84,percent of total billed charges,48.48% of total billed charges,115.65,90,,92.52,percent of total billed charges,90% of total billed charges,48.48,115.65,
SSA,41000193,CDM,300,RC,86235,HCPCS,outpatient,,,128.5,77.10,91,77.1,60,,61.68,percent of total billed charges,60% of total billed charges,61.68,48,,49.344,percent of total billed charges,48% of total billed charges,35.24,100,,,fee schedule,100% of bcbs custom fee schedule,35.24,100,,,fee schedule,100% of bcbs custom fee schedule,39.12,111,,,fee schedule,111% of bcbs custom fee schedule,64.25,50,,51.4,percent of total billed charges,50% of total billed charges,89.95,70,,71.96,percent of total billed charges,70% of total billed charges,62.3,48.48,,49.84,percent of total billed charges,48.48% of total billed charges,18.11,101,,,fee schedule,101% of cms custom fee schedule,62.3,48.48,,49.84,percent of total billed charges,48.48% of total billed charges,89.95,70,,71.96,percent of total billed charges,70% of total billed charges,89.95,70,,71.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,62.3,48.48,,49.84,percent of total billed charges,48.48% of total billed charges,115.65,90,,92.52,percent of total billed charges,90% of total billed charges,48.48,115.65,
Lactate Level,41000013,CDM,300,RC,83605,HCPCS,outpatient,,,137.5,82.50,,82.5,60,,66,percent of total billed charges,60% of total billed charges,66,48,,52.8,percent of total billed charges,48% of total billed charges,32.33,100,,,fee schedule,100% of bcbs custom fee schedule,32.33,100,,,fee schedule,100% of bcbs custom fee schedule,35.89,111,,,fee schedule,111% of bcbs custom fee schedule,68.75,50,,55,percent of total billed charges,50% of total billed charges,96.25,70,,77,percent of total billed charges,70% of total billed charges,66.66,48.48,,53.328,percent of total billed charges,48.48% of total billed charges,11.69,101,,,fee schedule,101% of cms custom fee schedule,66.66,48.48,,53.328,percent of total billed charges,48.48% of total billed charges,96.25,70,,77,percent of total billed charges,70% of total billed charges,96.25,70,,77,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,66.66,48.48,,53.328,percent of total billed charges,48.48% of total billed charges,123.75,90,,99,percent of total billed charges,90% of total billed charges,48.48,123.75,
SSB,41000193,CDM,300,RC,86235,HCPCS,outpatient,,,128.5,77.10,91,77.1,60,,61.68,percent of total billed charges,60% of total billed charges,61.68,48,,49.344,percent of total billed charges,48% of total billed charges,35.24,100,,,fee schedule,100% of bcbs custom fee schedule,35.24,100,,,fee schedule,100% of bcbs custom fee schedule,39.12,111,,,fee schedule,111% of bcbs custom fee schedule,64.25,50,,51.4,percent of total billed charges,50% of total billed charges,89.95,70,,71.96,percent of total billed charges,70% of total billed charges,62.3,48.48,,49.84,percent of total billed charges,48.48% of total billed charges,18.11,101,,,fee schedule,101% of cms custom fee schedule,62.3,48.48,,49.84,percent of total billed charges,48.48% of total billed charges,89.95,70,,71.96,percent of total billed charges,70% of total billed charges,89.95,70,,71.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,62.3,48.48,,49.84,percent of total billed charges,48.48% of total billed charges,115.65,90,,92.52,percent of total billed charges,90% of total billed charges,48.48,115.65,
ALT (SGPT),41000018,CDM,301,RC,84460,HCPCS,outpatient,,,73,43.80,,43.8,60,,35.04,percent of total billed charges,60% of total billed charges,35.04,48,,28.032,percent of total billed charges,48% of total billed charges,16.05,100,,,fee schedule,100% of bcbs custom fee schedule,16.05,100,,,fee schedule,100% of bcbs custom fee schedule,17.82,111,,,fee schedule,111% of bcbs custom fee schedule,36.5,50,,29.2,percent of total billed charges,50% of total billed charges,51.1,70,,40.88,percent of total billed charges,70% of total billed charges,35.39,48.48,,28.312,percent of total billed charges,48.48% of total billed charges,5.35,101,,,fee schedule,101% of cms custom fee schedule,35.39,48.48,,28.312,percent of total billed charges,48.48% of total billed charges,51.1,70,,40.88,percent of total billed charges,70% of total billed charges,51.1,70,,40.88,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,35.39,48.48,,28.312,percent of total billed charges,48.48% of total billed charges,65.7,90,,52.56,percent of total billed charges,90% of total billed charges,35.39,90,
ANTI DS DNA,41000226,CDM,300,RC,86225,HCPCS,outpatient,,,102.5,61.50,91,61.5,60,,49.2,percent of total billed charges,60% of total billed charges,49.2,48,,39.36,percent of total billed charges,48% of total billed charges,41.63,100,,,fee schedule,100% of bcbs custom fee schedule,41.63,100,,,fee schedule,100% of bcbs custom fee schedule,46.21,111,,,fee schedule,111% of bcbs custom fee schedule,51.25,50,,41,percent of total billed charges,50% of total billed charges,71.75,70,,57.4,percent of total billed charges,70% of total billed charges,49.69,48.48,,39.752,percent of total billed charges,48.48% of total billed charges,13.88,101,,,fee schedule,101% of cms custom fee schedule,49.69,48.48,,39.752,percent of total billed charges,48.48% of total billed charges,71.75,70,,57.4,percent of total billed charges,70% of total billed charges,71.75,70,,57.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,49.69,48.48,,39.752,percent of total billed charges,48.48% of total billed charges,92.25,90,,73.8,percent of total billed charges,90% of total billed charges,48.48,92.25,
RPR/VDRL QUALITATIVE,41000725,CDM,300,RC,86592,HCPCS,outpatient,,,43.5,26.10,,26.1,60,,20.88,percent of total billed charges,60% of total billed charges,20.88,48,,16.704,percent of total billed charges,48% of total billed charges,12.91,100,,,fee schedule,100% of bcbs custom fee schedule,12.91,100,,,fee schedule,100% of bcbs custom fee schedule,14.33,111,,,fee schedule,111% of bcbs custom fee schedule,21.75,50,,17.4,percent of total billed charges,50% of total billed charges,30.45,70,,24.36,percent of total billed charges,70% of total billed charges,21.09,48.48,,16.872,percent of total billed charges,48.48% of total billed charges,4.31,101,,,fee schedule,101% of cms custom fee schedule,21.09,48.48,,16.872,percent of total billed charges,48.48% of total billed charges,30.45,70,,24.36,percent of total billed charges,70% of total billed charges,30.45,70,,24.36,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,21.09,48.48,,16.872,percent of total billed charges,48.48% of total billed charges,39.15,90,,31.32,percent of total billed charges,90% of total billed charges,21.09,90,
ERYTHROPOIETIN LEVEL,41000162,CDM,300,RC,82668,HCPCS,outpatient,,,193.75,116.25,,116.25,60,,93,percent of total billed charges,60% of total billed charges,93,48,,74.4,percent of total billed charges,48% of total billed charges,56.92,100,,,fee schedule,100% of bcbs custom fee schedule,56.92,100,,,fee schedule,100% of bcbs custom fee schedule,63.18,111,,,fee schedule,111% of bcbs custom fee schedule,96.88,50,,77.504,percent of total billed charges,50% of total billed charges,135.63,70,,108.504,percent of total billed charges,70% of total billed charges,93.93,48.48,,75.144,percent of total billed charges,48.48% of total billed charges,18.98,101,,,fee schedule,101% of cms custom fee schedule,93.93,48.48,,75.144,percent of total billed charges,48.48% of total billed charges,135.63,70,,108.504,percent of total billed charges,70% of total billed charges,135.63,70,,108.504,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,93.93,48.48,,75.144,percent of total billed charges,48.48% of total billed charges,174.38,90,,139.504,percent of total billed charges,90% of total billed charges,48.48,174.38,
IGF / SOMATOMEDIN,41000391,CDM,300,RC,84305,HCPCS,outpatient,,,275,165.00,,165,60,,132,percent of total billed charges,60% of total billed charges,132,48,,105.6,percent of total billed charges,48% of total billed charges,59.46,100,,,fee schedule,100% of bcbs custom fee schedule,59.46,100,,,fee schedule,100% of bcbs custom fee schedule,66,111,,,fee schedule,111% of bcbs custom fee schedule,137.5,50,,110,percent of total billed charges,50% of total billed charges,192.5,70,,154,percent of total billed charges,70% of total billed charges,133.32,48.48,,106.656,percent of total billed charges,48.48% of total billed charges,21.47,101,,,fee schedule,101% of cms custom fee schedule,133.32,48.48,,106.656,percent of total billed charges,48.48% of total billed charges,192.5,70,,154,percent of total billed charges,70% of total billed charges,192.5,70,,154,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,133.32,48.48,,106.656,percent of total billed charges,48.48% of total billed charges,247.5,90,,198,percent of total billed charges,90% of total billed charges,48.48,247.5,
PAP (SCREENING),43601158,CDM,770,RC,Q0091,HCPCS,outpatient,,,61.25,36.75,TC,36.75,60,,29.4,percent of total billed charges,60% of total billed charges,29.4,48,,23.52,percent of total billed charges,48% of total billed charges,30.63,50,,24.504,percent of total billed charges,50% of total billed charges,30.63,50,,24.504,percent of total billed charges,50% of total billed charges,30.63,50,,24.504,percent of total billed charges,50% of total billed charges,30.63,50,,24.504,percent of total billed charges,50% of total billed charges,42.88,70,,34.304,percent of total billed charges,70% of total billed charges,29.69,48.48,,23.752,percent of total billed charges,48.48% of total billed charges,20.27,116.15,,,fee schedule,116.51% of cms physician fee schedule,29.69,48.48,,23.752,percent of total billed charges,48.48% of total billed charges,42.88,70,,34.304,percent of total billed charges,70% of total billed charges,42.88,70,,34.304,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,29.69,48.48,,23.752,percent of total billed charges,48.48% of total billed charges,55.13,90,,44.104,percent of total billed charges,90% of total billed charges,29.69,90,
UREA CLEARANCE,41000089,CDM,300,RC,84540,HCPCS,outpatient,,,88,52.80,,52.8,60,,42.24,percent of total billed charges,60% of total billed charges,42.24,48,,33.792,percent of total billed charges,48% of total billed charges,14.09,100,,,fee schedule,100% of bcbs custom fee schedule,14.09,100,,,fee schedule,100% of bcbs custom fee schedule,15.64,111,,,fee schedule,111% of bcbs custom fee schedule,44,50,,35.2,percent of total billed charges,50% of total billed charges,61.6,70,,49.28,percent of total billed charges,70% of total billed charges,42.66,48.48,,34.128,percent of total billed charges,48.48% of total billed charges,5.62,101,,,fee schedule,101% of cms custom fee schedule,42.66,48.48,,34.128,percent of total billed charges,48.48% of total billed charges,61.6,70,,49.28,percent of total billed charges,70% of total billed charges,61.6,70,,49.28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,42.66,48.48,,34.128,percent of total billed charges,48.48% of total billed charges,79.2,90,,63.36,percent of total billed charges,90% of total billed charges,42.66,90,
PHLEBOTOMY THERAP,32000011,CDM,940,RC,99195,HCPCS,outpatient,,,122.5,73.50,,73.5,60,,58.8,percent of total billed charges,60% of total billed charges,58.8,48,,47.04,percent of total billed charges,48% of total billed charges,73.07,100,,,fee schedule,100% of bcbs custom fee schedule,73.07,100,,,fee schedule,100% of bcbs custom fee schedule,81.11,111,,,fee schedule,111% of bcbs custom fee schedule,61.25,50,,49,percent of total billed charges,50% of total billed charges,85.75,70,,68.6,percent of total billed charges,70% of total billed charges,59.39,48.48,,47.512,percent of total billed charges,48.48% of total billed charges,97.82,116.15,,,fee schedule,116.51% of cms physician fee schedule,59.39,48.48,,47.512,percent of total billed charges,48.48% of total billed charges,85.75,70,,68.6,percent of total billed charges,70% of total billed charges,85.75,70,,68.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,59.39,48.48,,47.512,percent of total billed charges,48.48% of total billed charges,110.25,90,,88.2,percent of total billed charges,90% of total billed charges,48.48,110.25,
DAT (COOMBS),41040205,CDM,390,RC,86880,HCPCS,outpatient,,,93.75,56.25,,56.25,60,,45,percent of total billed charges,60% of total billed charges,45,48,,36,percent of total billed charges,48% of total billed charges,16.26,100,,,fee schedule,100% of bcbs custom fee schedule,16.26,100,,,fee schedule,100% of bcbs custom fee schedule,18.05,111,,,fee schedule,111% of bcbs custom fee schedule,46.88,50,,37.504,percent of total billed charges,50% of total billed charges,65.63,70,,52.504,percent of total billed charges,70% of total billed charges,45.45,48.48,,36.36,percent of total billed charges,48.48% of total billed charges,5.44,101,,,fee schedule,101% of cms custom fee schedule,45.45,48.48,,36.36,percent of total billed charges,48.48% of total billed charges,65.63,70,,52.504,percent of total billed charges,70% of total billed charges,65.63,70,,52.504,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,45.45,48.48,,36.36,percent of total billed charges,48.48% of total billed charges,84.38,90,,67.504,percent of total billed charges,90% of total billed charges,45.45,90,
Ca 27-29,41000010,CDM,300,RC,86300,HCPCS,outpatient,,,150,90.00,,90,60,,72,percent of total billed charges,60% of total billed charges,72,48,,57.6,percent of total billed charges,48% of total billed charges,63.02,100,,,fee schedule,100% of bcbs custom fee schedule,63.02,100,,,fee schedule,100% of bcbs custom fee schedule,69.95,111,,,fee schedule,111% of bcbs custom fee schedule,75,50,,60,percent of total billed charges,50% of total billed charges,105,70,,84,percent of total billed charges,70% of total billed charges,72.72,48.48,,58.176,percent of total billed charges,48.48% of total billed charges,21.02,101,,,fee schedule,101% of cms custom fee schedule,72.72,48.48,,58.176,percent of total billed charges,48.48% of total billed charges,105,70,,84,percent of total billed charges,70% of total billed charges,105,70,,84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,72.72,48.48,,58.176,percent of total billed charges,48.48% of total billed charges,135,90,,108,percent of total billed charges,90% of total billed charges,48.48,135,
ASO ANTI-STREPTOLYSIN O,41000908,CDM,300,RC,86063,HCPCS,outpatient,,,73.75,44.25,,44.25,60,,35.4,percent of total billed charges,60% of total billed charges,35.4,48,,28.32,percent of total billed charges,48% of total billed charges,17.5,100,,,fee schedule,100% of bcbs custom fee schedule,17.5,100,,,fee schedule,100% of bcbs custom fee schedule,19.43,111,,,fee schedule,111% of bcbs custom fee schedule,36.88,50,,29.504,percent of total billed charges,50% of total billed charges,51.63,70,,41.304,percent of total billed charges,70% of total billed charges,35.75,48.48,,28.6,percent of total billed charges,48.48% of total billed charges,5.83,101,,,fee schedule,101% of cms custom fee schedule,35.75,48.48,,28.6,percent of total billed charges,48.48% of total billed charges,51.63,70,,41.304,percent of total billed charges,70% of total billed charges,51.63,70,,41.304,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,35.75,48.48,,28.6,percent of total billed charges,48.48% of total billed charges,66.38,90,,53.104,percent of total billed charges,90% of total billed charges,35.75,90,
INFLUENZA A,43600313,CDM,302,RC,87804,HCPCS,outpatient,,,58.5,35.10,,35.1,60,,28.08,percent of total billed charges,60% of total billed charges,28.08,48,,22.464,percent of total billed charges,48% of total billed charges,36.33,100,,,fee schedule,100% of bcbs custom fee schedule,36.33,100,,,fee schedule,100% of bcbs custom fee schedule,40.33,111,,,fee schedule,111% of bcbs custom fee schedule,29.25,50,,23.4,percent of total billed charges,50% of total billed charges,40.95,70,,32.76,percent of total billed charges,70% of total billed charges,28.36,48.48,,22.688,percent of total billed charges,48.48% of total billed charges,16.72,101,,,fee schedule,101% of cms custom fee schedule,28.36,48.48,,22.688,percent of total billed charges,48.48% of total billed charges,40.95,70,,32.76,percent of total billed charges,70% of total billed charges,40.95,70,,32.76,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,28.36,48.48,,22.688,percent of total billed charges,48.48% of total billed charges,52.65,90,,42.12,percent of total billed charges,90% of total billed charges,28.36,90,
GLOMERULAR BASEMENT MEMBRANE ANTIBODY,41000540,CDM,300,RC,83520,HCPCS,outpatient,,,230,138.00,91,138,60,,110.4,percent of total billed charges,60% of total billed charges,110.4,48,,88.32,percent of total billed charges,48% of total billed charges,39.22,100,,,fee schedule,100% of bcbs custom fee schedule,39.22,100,,,fee schedule,100% of bcbs custom fee schedule,43.53,111,,,fee schedule,111% of bcbs custom fee schedule,115,50,,92,percent of total billed charges,50% of total billed charges,161,70,,128.8,percent of total billed charges,70% of total billed charges,111.5,48.48,,89.2,percent of total billed charges,48.48% of total billed charges,17.44,101,,,fee schedule,101% of cms custom fee schedule,111.5,48.48,,89.2,percent of total billed charges,48.48% of total billed charges,161,70,,128.8,percent of total billed charges,70% of total billed charges,161,70,,128.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,111.5,48.48,,89.2,percent of total billed charges,48.48% of total billed charges,207,90,,165.6,percent of total billed charges,90% of total billed charges,48.48,207,
ARTERIAL PUNCTURE,41009053,CDM,300,RC,36600,HCPCS,outpatient,,,96,57.60,,57.6,60,,46.08,percent of total billed charges,60% of total billed charges,46.08,48,,36.864,percent of total billed charges,48% of total billed charges,1.16,100,,,fee schedule,100% of bcbs custom fee schedule,1.16,100,,,fee schedule,100% of bcbs custom fee schedule,1.29,111,,,fee schedule,111% of bcbs custom fee schedule,48,50,,38.4,percent of total billed charges,50% of total billed charges,67.2,70,,53.76,percent of total billed charges,70% of total billed charges,46.54,48.48,,37.232,percent of total billed charges,48.48% of total billed charges,16.63,116.15,,,fee schedule,116.51% of cms physician fee schedule,46.54,48.48,,37.232,percent of total billed charges,48.48% of total billed charges,67.2,70,,53.76,percent of total billed charges,70% of total billed charges,67.2,70,,53.76,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,46.54,48.48,,37.232,percent of total billed charges,48.48% of total billed charges,86.4,90,,69.12,percent of total billed charges,90% of total billed charges,46.54,90,
HEPATITIS B SURFACE ANTIBODY,41000442,CDM,300,RC,86706,HCPCS,outpatient,,,85.5,51.30,,51.3,60,,41.04,percent of total billed charges,60% of total billed charges,41.04,48,,32.832,percent of total billed charges,48% of total billed charges,32.53,100,,,fee schedule,100% of bcbs custom fee schedule,32.53,100,,,fee schedule,100% of bcbs custom fee schedule,36.11,111,,,fee schedule,111% of bcbs custom fee schedule,42.75,50,,34.2,percent of total billed charges,50% of total billed charges,59.85,70,,47.88,percent of total billed charges,70% of total billed charges,41.45,48.48,,33.16,percent of total billed charges,48.48% of total billed charges,10.85,101,,,fee schedule,101% of cms custom fee schedule,41.45,48.48,,33.16,percent of total billed charges,48.48% of total billed charges,59.85,70,,47.88,percent of total billed charges,70% of total billed charges,59.85,70,,47.88,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,41.45,48.48,,33.16,percent of total billed charges,48.48% of total billed charges,76.95,90,,61.56,percent of total billed charges,90% of total billed charges,41.45,90,
"Immunoglobulins, QT Kappa/Lambda",,,300,RC,83521,HCPCS,outpatient,,,45,27.00,91,27,60,,21.6,percent of total billed charges,60% of total billed charges,21.6,48,,17.28,percent of total billed charges,48% of total billed charges,22.5,50,,18,percent of total billed charges,50% of total billed charges,22.5,50,,18,percent of total billed charges,50% of total billed charges,22.5,50,,18,percent of total billed charges,50% of total billed charges,22.5,50,,18,percent of total billed charges,50% of total billed charges,31.5,70,,25.2,percent of total billed charges,70% of total billed charges,21.82,48.48,,17.456,percent of total billed charges,48.48% of total billed charges,17.44,101,,,fee schedule,101% of cms custom fee schedule,21.82,48.48,,17.456,percent of total billed charges,48.48% of total billed charges,31.5,70,,25.2,percent of total billed charges,70% of total billed charges,31.5,70,,25.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,21.82,48.48,,17.456,percent of total billed charges,48.48% of total billed charges,40.5,90,,32.4,percent of total billed charges,90% of total billed charges,21.82,90,
PROGESTERONE,41001019,CDM,300,RC,84144,HCPCS,outpatient,,,129,77.40,,77.4,60,,61.92,percent of total billed charges,60% of total billed charges,61.92,48,,49.536,percent of total billed charges,48% of total billed charges,63.19,100,,,fee schedule,100% of bcbs custom fee schedule,63.19,100,,,fee schedule,100% of bcbs custom fee schedule,70.14,111,,,fee schedule,111% of bcbs custom fee schedule,64.5,50,,51.6,percent of total billed charges,50% of total billed charges,90.3,70,,72.24,percent of total billed charges,70% of total billed charges,62.54,48.48,,50.032,percent of total billed charges,48.48% of total billed charges,21.07,101,,,fee schedule,101% of cms custom fee schedule,62.54,48.48,,50.032,percent of total billed charges,48.48% of total billed charges,90.3,70,,72.24,percent of total billed charges,70% of total billed charges,90.3,70,,72.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,62.54,48.48,,50.032,percent of total billed charges,48.48% of total billed charges,116.1,90,,92.88,percent of total billed charges,90% of total billed charges,48.48,116.1,
NEISSERIA GONORRHOEAE DNA PROBE,,,300,RC,87591,HCPCS,outpatient,,,65,39.00,,39,60,,31.2,percent of total billed charges,60% of total billed charges,31.2,48,,24.96,percent of total billed charges,48% of total billed charges,106.32,100,,,fee schedule,100% of bcbs custom fee schedule,106.32,100,,,fee schedule,100% of bcbs custom fee schedule,118.02,111,,,fee schedule,111% of bcbs custom fee schedule,32.5,50,,26,percent of total billed charges,50% of total billed charges,45.5,70,,36.4,percent of total billed charges,70% of total billed charges,31.51,48.48,,25.208,percent of total billed charges,48.48% of total billed charges,35.44,101,,,fee schedule,101% of cms custom fee schedule,31.51,48.48,,25.208,percent of total billed charges,48.48% of total billed charges,45.5,70,,36.4,percent of total billed charges,70% of total billed charges,45.5,70,,36.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,31.51,48.48,,25.208,percent of total billed charges,48.48% of total billed charges,58.5,90,,46.8,percent of total billed charges,90% of total billed charges,31.51,90,
"1,25 DIHYDROXY VITAMIN D",41001032,CDM,300,RC,82652,HCPCS,outpatient,,,537.5,322.50,,322.5,60,,258,percent of total billed charges,60% of total billed charges,258,48,,206.4,percent of total billed charges,48% of total billed charges,116.58,100,,,fee schedule,100% of bcbs custom fee schedule,116.58,100,,,fee schedule,100% of bcbs custom fee schedule,129.4,111,,,fee schedule,111% of bcbs custom fee schedule,268.75,50,,215,percent of total billed charges,50% of total billed charges,376.25,70,,301,percent of total billed charges,70% of total billed charges,260.58,48.48,,208.464,percent of total billed charges,48.48% of total billed charges,38.89,101,,,fee schedule,101% of cms custom fee schedule,260.58,48.48,,208.464,percent of total billed charges,48.48% of total billed charges,376.25,70,,301,percent of total billed charges,70% of total billed charges,376.25,70,,301,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,260.58,48.48,,208.464,percent of total billed charges,48.48% of total billed charges,483.75,90,,387,percent of total billed charges,90% of total billed charges,48.48,483.75,
PROTEIN ELECTROPHORESIS- URINE/CSF,41000409,CDM,300,RC,84166,HCPCS,outpatient,,,273.75,164.25,,164.25,60,,131.4,percent of total billed charges,60% of total billed charges,131.4,48,,105.12,percent of total billed charges,48% of total billed charges,54.01,100,,,fee schedule,100% of bcbs custom fee schedule,54.01,100,,,fee schedule,100% of bcbs custom fee schedule,59.95,111,,,fee schedule,111% of bcbs custom fee schedule,136.88,50,,109.504,percent of total billed charges,50% of total billed charges,191.63,70,,153.304,percent of total billed charges,70% of total billed charges,132.71,48.48,,106.168,percent of total billed charges,48.48% of total billed charges,18.01,101,,,fee schedule,101% of cms custom fee schedule,132.71,48.48,,106.168,percent of total billed charges,48.48% of total billed charges,191.63,70,,153.304,percent of total billed charges,70% of total billed charges,191.63,70,,153.304,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,132.71,48.48,,106.168,percent of total billed charges,48.48% of total billed charges,246.38,90,,197.104,percent of total billed charges,90% of total billed charges,48.48,246.38,
BNP,41009107,CDM,300,RC,83880,HCPCS,outpatient,,,176.5,105.90,,105.9,60,,84.72,percent of total billed charges,60% of total billed charges,84.72,48,,67.776,percent of total billed charges,48% of total billed charges,102.82,100,,,fee schedule,100% of bcbs custom fee schedule,102.82,100,,,fee schedule,100% of bcbs custom fee schedule,114.13,111,,,fee schedule,111% of bcbs custom fee schedule,88.25,50,,70.6,percent of total billed charges,50% of total billed charges,123.55,70,,98.84,percent of total billed charges,70% of total billed charges,85.57,48.48,,68.456,percent of total billed charges,48.48% of total billed charges,39.65,101,,,fee schedule,101% of cms custom fee schedule,85.57,48.48,,68.456,percent of total billed charges,48.48% of total billed charges,123.55,70,,98.84,percent of total billed charges,70% of total billed charges,123.55,70,,98.84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,85.57,48.48,,68.456,percent of total billed charges,48.48% of total billed charges,158.85,90,,127.08,percent of total billed charges,90% of total billed charges,48.48,158.85,
"IMMUNOFIXATION, SERUM",,,300,RC,86334,HCPCS,outpatient,,,245.5,147.30,,147.3,60,,117.84,percent of total billed charges,60% of total billed charges,117.84,48,,94.272,percent of total billed charges,48% of total billed charges,67.65,100,,,fee schedule,100% of bcbs custom fee schedule,67.65,100,,,fee schedule,100% of bcbs custom fee schedule,75.09,111,,,fee schedule,111% of bcbs custom fee schedule,122.75,50,,98.2,percent of total billed charges,50% of total billed charges,171.85,70,,137.48,percent of total billed charges,70% of total billed charges,119.02,48.48,,95.216,percent of total billed charges,48.48% of total billed charges,22.56,101,,,fee schedule,101% of cms custom fee schedule,119.02,48.48,,95.216,percent of total billed charges,48.48% of total billed charges,171.85,70,,137.48,percent of total billed charges,70% of total billed charges,171.85,70,,137.48,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,119.02,48.48,,95.216,percent of total billed charges,48.48% of total billed charges,220.95,90,,176.76,percent of total billed charges,90% of total billed charges,48.48,220.95,
HEPATITIS B SURFACE ANTIGEN,41001013,CDM,300,RC,87340,HCPCS,outpatient,,,75.5,45.30,,45.3,60,,36.24,percent of total billed charges,60% of total billed charges,36.24,48,,28.992,percent of total billed charges,48% of total billed charges,31.28,100,,,fee schedule,100% of bcbs custom fee schedule,31.28,100,,,fee schedule,100% of bcbs custom fee schedule,34.72,111,,,fee schedule,111% of bcbs custom fee schedule,37.75,50,,30.2,percent of total billed charges,50% of total billed charges,52.85,70,,42.28,percent of total billed charges,70% of total billed charges,36.6,48.48,,29.28,percent of total billed charges,48.48% of total billed charges,10.43,101,,,fee schedule,101% of cms custom fee schedule,36.6,48.48,,29.28,percent of total billed charges,48.48% of total billed charges,52.85,70,,42.28,percent of total billed charges,70% of total billed charges,52.85,70,,42.28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,36.6,48.48,,29.28,percent of total billed charges,48.48% of total billed charges,67.95,90,,54.36,percent of total billed charges,90% of total billed charges,36.6,90,
ANTIBODY TO T PALLIDUM,41000231,CDM,300,RC,86780,HCPCS,outpatient,,,96,57.60,,57.6,60,,46.08,percent of total billed charges,60% of total billed charges,46.08,48,,36.864,percent of total billed charges,48% of total billed charges,28.56,100,,,fee schedule,100% of bcbs custom fee schedule,28.56,100,,,fee schedule,100% of bcbs custom fee schedule,31.7,111,,,fee schedule,111% of bcbs custom fee schedule,48,50,,38.4,percent of total billed charges,50% of total billed charges,67.2,70,,53.76,percent of total billed charges,70% of total billed charges,46.54,48.48,,37.232,percent of total billed charges,48.48% of total billed charges,13.37,101,,,fee schedule,101% of cms custom fee schedule,46.54,48.48,,37.232,percent of total billed charges,48.48% of total billed charges,67.2,70,,53.76,percent of total billed charges,70% of total billed charges,67.2,70,,53.76,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,46.54,48.48,,37.232,percent of total billed charges,48.48% of total billed charges,86.4,90,,69.12,percent of total billed charges,90% of total billed charges,46.54,90,
Ca 15-3,41000010,CDM,300,RC,86300,HCPCS,outpatient,,,250,150.00,,150,60,,120,percent of total billed charges,60% of total billed charges,120,48,,96,percent of total billed charges,48% of total billed charges,63.02,100,,,fee schedule,100% of bcbs custom fee schedule,63.02,100,,,fee schedule,100% of bcbs custom fee schedule,69.95,111,,,fee schedule,111% of bcbs custom fee schedule,125,50,,100,percent of total billed charges,50% of total billed charges,175,70,,140,percent of total billed charges,70% of total billed charges,121.2,48.48,,96.96,percent of total billed charges,48.48% of total billed charges,21.02,101,,,fee schedule,101% of cms custom fee schedule,121.2,48.48,,96.96,percent of total billed charges,48.48% of total billed charges,175,70,,140,percent of total billed charges,70% of total billed charges,175,70,,140,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,121.2,48.48,,96.96,percent of total billed charges,48.48% of total billed charges,225,90,,180,percent of total billed charges,90% of total billed charges,48.48,225,
RENAL FUNCTION PANEL,41009148,CDM,301,RC,80069,HCPCS,outpatient,,,113.75,68.25,,68.25,60,,54.6,percent of total billed charges,60% of total billed charges,54.6,48,,43.68,percent of total billed charges,48% of total billed charges,26.3,100,,,fee schedule,100% of bcbs custom fee schedule,26.3,100,,,fee schedule,100% of bcbs custom fee schedule,29.19,111,,,fee schedule,111% of bcbs custom fee schedule,56.88,50,,45.504,percent of total billed charges,50% of total billed charges,79.63,70,,63.704,percent of total billed charges,70% of total billed charges,55.15,48.48,,44.12,percent of total billed charges,48.48% of total billed charges,8.77,101,,,fee schedule,101% of cms custom fee schedule,55.15,48.48,,44.12,percent of total billed charges,48.48% of total billed charges,79.63,70,,63.704,percent of total billed charges,70% of total billed charges,79.63,70,,63.704,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,55.15,48.48,,44.12,percent of total billed charges,48.48% of total billed charges,102.38,90,,81.904,percent of total billed charges,90% of total billed charges,48.48,102.38,
"METANEPHRINES, FRACTIONATED",41000031,CDM,300,RC,83835,HCPCS,outpatient,,,260,156.00,,156,60,,124.8,percent of total billed charges,60% of total billed charges,124.8,48,,99.84,percent of total billed charges,48% of total billed charges,51.3,100,,,fee schedule,100% of bcbs custom fee schedule,51.3,100,,,fee schedule,100% of bcbs custom fee schedule,56.94,111,,,fee schedule,111% of bcbs custom fee schedule,130,50,,104,percent of total billed charges,50% of total billed charges,182,70,,145.6,percent of total billed charges,70% of total billed charges,126.05,48.48,,100.84,percent of total billed charges,48.48% of total billed charges,17.11,101,,,fee schedule,101% of cms custom fee schedule,126.05,48.48,,100.84,percent of total billed charges,48.48% of total billed charges,182,70,,145.6,percent of total billed charges,70% of total billed charges,182,70,,145.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,126.05,48.48,,100.84,percent of total billed charges,48.48% of total billed charges,234,90,,187.2,percent of total billed charges,90% of total billed charges,48.48,234,
COMPREHEN METABOLIC PANEL,41000366,CDM,301,RC,80053,HCPCS,outpatient,,,147.5,88.50,,15,100,,,fee schedule,100% of aetna fee schedule,70.8,48,,56.64,percent of total billed charges,48% of total billed charges,32.02,100,,,fee schedule,100% of bcbs custom fee schedule,32.02,100,,,fee schedule,100% of bcbs custom fee schedule,35.54,111,,,fee schedule,111% of bcbs custom fee schedule,73.75,50,,59,percent of total billed charges,50% of total billed charges,103.25,70,,82.6,percent of total billed charges,70% of total billed charges,71.51,48.48,,57.208,percent of total billed charges,48.48% of total billed charges,10.67,101,,,fee schedule,101% of cms custom fee schedule,71.51,48.48,,57.208,percent of total billed charges,48.48% of total billed charges,103.25,70,,82.6,percent of total billed charges,70% of total billed charges,103.25,70,,82.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,71.51,48.48,,57.208,percent of total billed charges,48.48% of total billed charges,132.75,90,,106.2,percent of total billed charges,90% of total billed charges,48.48,132.75,
"CATECHOLAMINES, FRACTIONATED, 24HR",41000178,CDM,300,RC,82384,HCPCS,outpatient,,,191,114.60,,114.6,60,,91.68,percent of total billed charges,60% of total billed charges,91.68,48,,73.344,percent of total billed charges,48% of total billed charges,76.47,100,,,fee schedule,100% of bcbs custom fee schedule,76.47,100,,,fee schedule,100% of bcbs custom fee schedule,84.88,111,,,fee schedule,111% of bcbs custom fee schedule,95.5,50,,76.4,percent of total billed charges,50% of total billed charges,133.7,70,,106.96,percent of total billed charges,70% of total billed charges,92.6,48.48,,74.08,percent of total billed charges,48.48% of total billed charges,25.5,101,,,fee schedule,101% of cms custom fee schedule,92.6,48.48,,74.08,percent of total billed charges,48.48% of total billed charges,133.7,70,,106.96,percent of total billed charges,70% of total billed charges,133.7,70,,106.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,92.6,48.48,,74.08,percent of total billed charges,48.48% of total billed charges,171.9,90,,137.52,percent of total billed charges,90% of total billed charges,48.48,171.9,
VON WILLEBRAND FACTOR ACTIVITY,41000364,CDM,300,RC,85246,HCPCS,outpatient,,,250,150.00,,150,60,,120,percent of total billed charges,60% of total billed charges,120,48,,96,percent of total billed charges,48% of total billed charges,69.5,100,,,fee schedule,100% of bcbs custom fee schedule,69.5,100,,,fee schedule,100% of bcbs custom fee schedule,77.15,111,,,fee schedule,111% of bcbs custom fee schedule,125,50,,100,percent of total billed charges,50% of total billed charges,175,70,,140,percent of total billed charges,70% of total billed charges,121.2,48.48,,96.96,percent of total billed charges,48.48% of total billed charges,23.17,101,,,fee schedule,101% of cms custom fee schedule,121.2,48.48,,96.96,percent of total billed charges,48.48% of total billed charges,175,70,,140,percent of total billed charges,70% of total billed charges,175,70,,140,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,121.2,48.48,,96.96,percent of total billed charges,48.48% of total billed charges,225,90,,180,percent of total billed charges,90% of total billed charges,48.48,225,
ISLET CELL ANTIBODY,41000392,CDM,300,RC,86341,HCPCS,outpatient,,,180,108.00,91,108,60,,86.4,percent of total billed charges,60% of total billed charges,86.4,48,,69.12,percent of total billed charges,48% of total billed charges,59.95,100,,,fee schedule,100% of bcbs custom fee schedule,59.95,100,,,fee schedule,100% of bcbs custom fee schedule,66.54,111,,,fee schedule,111% of bcbs custom fee schedule,90,50,,72,percent of total billed charges,50% of total billed charges,126,70,,100.8,percent of total billed charges,70% of total billed charges,87.26,48.48,,69.808,percent of total billed charges,48.48% of total billed charges,23.81,101,,,fee schedule,101% of cms custom fee schedule,87.26,48.48,,69.808,percent of total billed charges,48.48% of total billed charges,126,70,,100.8,percent of total billed charges,70% of total billed charges,126,70,,100.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,87.26,48.48,,69.808,percent of total billed charges,48.48% of total billed charges,162,90,,129.6,percent of total billed charges,90% of total billed charges,48.48,162,
SCL70 Antibody,41000193,CDM,300,RC,86235,HCPCS,outpatient,,,128.5,77.10,91,77.1,60,,61.68,percent of total billed charges,60% of total billed charges,61.68,48,,49.344,percent of total billed charges,48% of total billed charges,35.24,100,,,fee schedule,100% of bcbs custom fee schedule,35.24,100,,,fee schedule,100% of bcbs custom fee schedule,39.12,111,,,fee schedule,111% of bcbs custom fee schedule,64.25,50,,51.4,percent of total billed charges,50% of total billed charges,89.95,70,,71.96,percent of total billed charges,70% of total billed charges,62.3,48.48,,49.84,percent of total billed charges,48.48% of total billed charges,18.11,101,,,fee schedule,101% of cms custom fee schedule,62.3,48.48,,49.84,percent of total billed charges,48.48% of total billed charges,89.95,70,,71.96,percent of total billed charges,70% of total billed charges,89.95,70,,71.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,62.3,48.48,,49.84,percent of total billed charges,48.48% of total billed charges,115.65,90,,92.52,percent of total billed charges,90% of total billed charges,48.48,115.65,
CREATININE CLEARANCE,41000066,CDM,300,RC,82575,HCPCS,outpatient,,,49,29.40,,29.4,60,,23.52,percent of total billed charges,60% of total billed charges,23.52,48,,18.816,percent of total billed charges,48% of total billed charges,28.61,100,,,fee schedule,100% of bcbs custom fee schedule,28.61,100,,,fee schedule,100% of bcbs custom fee schedule,31.76,111,,,fee schedule,111% of bcbs custom fee schedule,24.5,50,,19.6,percent of total billed charges,50% of total billed charges,34.3,70,,27.44,percent of total billed charges,70% of total billed charges,23.76,48.48,,19.008,percent of total billed charges,48.48% of total billed charges,9.55,101,,,fee schedule,101% of cms custom fee schedule,23.76,48.48,,19.008,percent of total billed charges,48.48% of total billed charges,34.3,70,,27.44,percent of total billed charges,70% of total billed charges,34.3,70,,27.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,23.76,48.48,,19.008,percent of total billed charges,48.48% of total billed charges,44.1,90,,35.28,percent of total billed charges,90% of total billed charges,23.76,90,
DRUG SCREEN COLLECTION FE,,,300,RC,84999,HCPCS,outpatient,,,43.75,26.25,,26.25,60,,21,percent of total billed charges,60% of total billed charges,21,48,,16.8,percent of total billed charges,48% of total billed charges,7.16,100,,,fee schedule,100% of bcbs custom fee schedule,7.16,100,,,fee schedule,100% of bcbs custom fee schedule,7.95,111,,,fee schedule,111% of bcbs custom fee schedule,21.88,50,,17.504,percent of total billed charges,50% of total billed charges,30.63,70,,24.504,percent of total billed charges,70% of total billed charges,21.21,48.48,,16.968,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,21.21,48.48,,16.968,percent of total billed charges,48.48% of total billed charges,30.63,70,,24.504,percent of total billed charges,70% of total billed charges,30.63,70,,24.504,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,21.21,48.48,,16.968,percent of total billed charges,48.48% of total billed charges,39.38,90,,31.504,percent of total billed charges,90% of total billed charges,21.21,90,
FACTOR VIII ACTIVITY,,,300,RC,85240,HCPCS,outpatient,,,252.12,151.27,,151.27,60,,121.016,percent of total billed charges,60% of total billed charges,121.02,48,,96.816,percent of total billed charges,48% of total billed charges,54.24,100,,,fee schedule,100% of bcbs custom fee schedule,54.24,100,,,fee schedule,100% of bcbs custom fee schedule,60.21,111,,,fee schedule,111% of bcbs custom fee schedule,126.06,50,,100.848,percent of total billed charges,50% of total billed charges,176.48,70,,141.184,percent of total billed charges,70% of total billed charges,122.23,48.48,,97.784,percent of total billed charges,48.48% of total billed charges,18.08,101,,,fee schedule,101% of cms custom fee schedule,122.23,48.48,,97.784,percent of total billed charges,48.48% of total billed charges,176.48,70,,141.184,percent of total billed charges,70% of total billed charges,176.48,70,,141.184,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,122.23,48.48,,97.784,percent of total billed charges,48.48% of total billed charges,226.91,90,,181.528,percent of total billed charges,90% of total billed charges,48.48,226.91,
DRUG SCREEN send off,,,300,RC,80307,HCPCS,outpatient,,,125,75.00,,75,60,,60,percent of total billed charges,60% of total billed charges,60,48,,48,percent of total billed charges,48% of total billed charges,145,100,,,fee schedule,100% of bcbs custom fee schedule,145,100,,,fee schedule,100% of bcbs custom fee schedule,160.95,111,,,fee schedule,111% of bcbs custom fee schedule,62.5,50,,50,percent of total billed charges,50% of total billed charges,87.5,70,,70,percent of total billed charges,70% of total billed charges,60.6,48.48,,48.48,percent of total billed charges,48.48% of total billed charges,62.76,101,,,fee schedule,101% of cms custom fee schedule,60.6,48.48,,48.48,percent of total billed charges,48.48% of total billed charges,87.5,70,,70,percent of total billed charges,70% of total billed charges,87.5,70,,70,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,60.6,48.48,,48.48,percent of total billed charges,48.48% of total billed charges,112.5,90,,90,percent of total billed charges,90% of total billed charges,48.48,112.5,
DRUG LEVEL NOS,,,300,RC,80377,HCPCS,outpatient,,,202,121.20,,121.2,60,,96.96,percent of total billed charges,60% of total billed charges,96.96,48,,77.568,percent of total billed charges,48% of total billed charges,17.88,100,,,fee schedule,100% of bcbs custom fee schedule,17.88,100,,,fee schedule,100% of bcbs custom fee schedule,19.85,111,,,fee schedule,111% of bcbs custom fee schedule,101,50,,80.8,percent of total billed charges,50% of total billed charges,141.4,70,,113.12,percent of total billed charges,70% of total billed charges,97.93,48.48,,78.344,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,97.93,48.48,,78.344,percent of total billed charges,48.48% of total billed charges,141.4,70,,113.12,percent of total billed charges,70% of total billed charges,141.4,70,,113.12,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,97.93,48.48,,78.344,percent of total billed charges,48.48% of total billed charges,181.8,90,,145.44,percent of total billed charges,90% of total billed charges,48.48,181.8,
MICROSCOPIC UA,41000761,CDM,307,RC,81015,HCPCS,outpatient,,,32.5,19.50,,19.5,60,,15.6,percent of total billed charges,60% of total billed charges,15.6,48,,12.48,percent of total billed charges,48% of total billed charges,9.19,100,,,fee schedule,100% of bcbs custom fee schedule,9.19,100,,,fee schedule,100% of bcbs custom fee schedule,10.2,111,,,fee schedule,111% of bcbs custom fee schedule,16.25,50,,13,percent of total billed charges,50% of total billed charges,22.75,70,,18.2,percent of total billed charges,70% of total billed charges,15.76,48.48,,12.608,percent of total billed charges,48.48% of total billed charges,3.08,101,,,fee schedule,101% of cms custom fee schedule,15.76,48.48,,12.608,percent of total billed charges,48.48% of total billed charges,22.75,70,,18.2,percent of total billed charges,70% of total billed charges,22.75,70,,18.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,15.76,48.48,,12.608,percent of total billed charges,48.48% of total billed charges,29.25,90,,23.4,percent of total billed charges,90% of total billed charges,15.76,90,
BETA-HYDROXYBUTYRATE,41000219,CDM,300,RC,82010,HCPCS,outpatient,,,130,78.00,,78,60,,62.4,percent of total billed charges,60% of total billed charges,62.4,48,,49.92,percent of total billed charges,48% of total billed charges,24.75,100,,,fee schedule,100% of bcbs custom fee schedule,24.75,100,,,fee schedule,100% of bcbs custom fee schedule,27.47,111,,,fee schedule,111% of bcbs custom fee schedule,65,50,,52,percent of total billed charges,50% of total billed charges,91,70,,72.8,percent of total billed charges,70% of total billed charges,63.02,48.48,,50.416,percent of total billed charges,48.48% of total billed charges,8.25,101,,,fee schedule,101% of cms custom fee schedule,63.02,48.48,,50.416,percent of total billed charges,48.48% of total billed charges,91,70,,72.8,percent of total billed charges,70% of total billed charges,91,70,,72.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,63.02,48.48,,50.416,percent of total billed charges,48.48% of total billed charges,117,90,,93.6,percent of total billed charges,90% of total billed charges,48.48,117,
DIGOXIN (LANOXIN) LEVEL,41000454,CDM,301,RC,80162,HCPCS,outpatient,,,99,59.40,,59.4,60,,47.52,percent of total billed charges,60% of total billed charges,47.52,48,,38.016,percent of total billed charges,48% of total billed charges,40.21,100,,,fee schedule,100% of bcbs custom fee schedule,40.21,100,,,fee schedule,100% of bcbs custom fee schedule,44.63,111,,,fee schedule,111% of bcbs custom fee schedule,49.5,50,,39.6,percent of total billed charges,50% of total billed charges,69.3,70,,55.44,percent of total billed charges,70% of total billed charges,48,48.48,,38.4,percent of total billed charges,48.48% of total billed charges,13.41,101,,,fee schedule,101% of cms custom fee schedule,48,48.48,,38.4,percent of total billed charges,48.48% of total billed charges,69.3,70,,55.44,percent of total billed charges,70% of total billed charges,69.3,70,,55.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,48,48.48,,38.4,percent of total billed charges,48.48% of total billed charges,89.1,90,,71.28,percent of total billed charges,90% of total billed charges,48,90,
"H PYLORI ANTIGEN,  EIA, STOOL",41001251,CDM,300,RC,87338,HCPCS,outpatient,,,150,90.00,,90,60,,72,percent of total billed charges,60% of total billed charges,72,48,,57.6,percent of total billed charges,48% of total billed charges,14.08,100,,,fee schedule,100% of bcbs custom fee schedule,14.08,100,,,fee schedule,100% of bcbs custom fee schedule,15.63,111,,,fee schedule,111% of bcbs custom fee schedule,75,50,,60,percent of total billed charges,50% of total billed charges,105,70,,84,percent of total billed charges,70% of total billed charges,72.72,48.48,,58.176,percent of total billed charges,48.48% of total billed charges,14.52,101,,,fee schedule,101% of cms custom fee schedule,72.72,48.48,,58.176,percent of total billed charges,48.48% of total billed charges,105,70,,84,percent of total billed charges,70% of total billed charges,105,70,,84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,72.72,48.48,,58.176,percent of total billed charges,48.48% of total billed charges,135,90,,108,percent of total billed charges,90% of total billed charges,48.48,135,
"DILANTIN, FREE",41001042,CDM,300,RC,80186,HCPCS,outpatient,,,106.25,63.75,,63.75,60,,51,percent of total billed charges,60% of total billed charges,51,48,,40.8,percent of total billed charges,48% of total billed charges,41.69,100,,,fee schedule,100% of bcbs custom fee schedule,41.69,100,,,fee schedule,100% of bcbs custom fee schedule,46.28,111,,,fee schedule,111% of bcbs custom fee schedule,53.13,50,,42.504,percent of total billed charges,50% of total billed charges,74.38,70,,59.504,percent of total billed charges,70% of total billed charges,51.51,48.48,,41.208,percent of total billed charges,48.48% of total billed charges,13.9,101,,,fee schedule,101% of cms custom fee schedule,51.51,48.48,,41.208,percent of total billed charges,48.48% of total billed charges,74.38,70,,59.504,percent of total billed charges,70% of total billed charges,74.38,70,,59.504,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,51.51,48.48,,41.208,percent of total billed charges,48.48% of total billed charges,95.63,90,,76.504,percent of total billed charges,90% of total billed charges,48.48,95.63,
AFP/AFP-L3,,,300,RC,82107,HCPCS,outpatient,,,312.5,187.50,,187.5,60,,150,percent of total billed charges,60% of total billed charges,150,48,,120,percent of total billed charges,48% of total billed charges,164.64,100,,,fee schedule,100% of bcbs custom fee schedule,164.64,100,,,fee schedule,100% of bcbs custom fee schedule,182.75,111,,,fee schedule,111% of bcbs custom fee schedule,156.25,50,,125,percent of total billed charges,50% of total billed charges,218.75,70,,175,percent of total billed charges,70% of total billed charges,151.5,48.48,,121.2,percent of total billed charges,48.48% of total billed charges,65.05,101,,,fee schedule,101% of cms custom fee schedule,151.5,48.48,,121.2,percent of total billed charges,48.48% of total billed charges,218.75,70,,175,percent of total billed charges,70% of total billed charges,218.75,70,,175,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,151.5,48.48,,121.2,percent of total billed charges,48.48% of total billed charges,281.25,90,,225,percent of total billed charges,90% of total billed charges,48.48,281.25,
MAGNESIUM LEVEL,41000014,CDM,301,RC,83735,HCPCS,outpatient,,,85,51.00,,51,60,,40.8,percent of total billed charges,60% of total billed charges,40.8,48,,32.64,percent of total billed charges,48% of total billed charges,20.29,100,,,fee schedule,100% of bcbs custom fee schedule,20.29,100,,,fee schedule,100% of bcbs custom fee schedule,22.52,111,,,fee schedule,111% of bcbs custom fee schedule,42.5,50,,34,percent of total billed charges,50% of total billed charges,59.5,70,,47.6,percent of total billed charges,70% of total billed charges,41.21,48.48,,32.968,percent of total billed charges,48.48% of total billed charges,6.77,101,,,fee schedule,101% of cms custom fee schedule,41.21,48.48,,32.968,percent of total billed charges,48.48% of total billed charges,59.5,70,,47.6,percent of total billed charges,70% of total billed charges,59.5,70,,47.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,41.21,48.48,,32.968,percent of total billed charges,48.48% of total billed charges,76.5,90,,61.2,percent of total billed charges,90% of total billed charges,41.21,90,
DHEA-S,41009067,CDM,300,RC,82627,HCPCS,outpatient,,,183,109.80,,109.8,60,,87.84,percent of total billed charges,60% of total billed charges,87.84,48,,70.272,percent of total billed charges,48% of total billed charges,67.35,100,,,fee schedule,100% of bcbs custom fee schedule,67.35,100,,,fee schedule,100% of bcbs custom fee schedule,74.76,111,,,fee schedule,111% of bcbs custom fee schedule,91.5,50,,73.2,percent of total billed charges,50% of total billed charges,128.1,70,,102.48,percent of total billed charges,70% of total billed charges,88.72,48.48,,70.976,percent of total billed charges,48.48% of total billed charges,22.45,101,,,fee schedule,101% of cms custom fee schedule,88.72,48.48,,70.976,percent of total billed charges,48.48% of total billed charges,128.1,70,,102.48,percent of total billed charges,70% of total billed charges,128.1,70,,102.48,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,88.72,48.48,,70.976,percent of total billed charges,48.48% of total billed charges,164.7,90,,131.76,percent of total billed charges,90% of total billed charges,48.48,164.7,
THEOPHYLLINE,41000455,CDM,301,RC,80198,HCPCS,outpatient,,,121.5,72.90,,72.9,60,,58.32,percent of total billed charges,60% of total billed charges,58.32,48,,46.656,percent of total billed charges,48% of total billed charges,42.86,100,,,fee schedule,100% of bcbs custom fee schedule,42.86,100,,,fee schedule,100% of bcbs custom fee schedule,47.57,111,,,fee schedule,111% of bcbs custom fee schedule,60.75,50,,48.6,percent of total billed charges,50% of total billed charges,85.05,70,,68.04,percent of total billed charges,70% of total billed charges,58.9,48.48,,47.12,percent of total billed charges,48.48% of total billed charges,14.28,101,,,fee schedule,101% of cms custom fee schedule,58.9,48.48,,47.12,percent of total billed charges,48.48% of total billed charges,85.05,70,,68.04,percent of total billed charges,70% of total billed charges,85.05,70,,68.04,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,58.9,48.48,,47.12,percent of total billed charges,48.48% of total billed charges,109.35,90,,87.48,percent of total billed charges,90% of total billed charges,48.48,109.35,
HAPTOGLOBIN,41009002,CDM,300,RC,83010,HCPCS,outpatient,,,127.5,76.50,,76.5,60,,61.2,percent of total billed charges,60% of total billed charges,61.2,48,,48.96,percent of total billed charges,48% of total billed charges,38.12,100,,,fee schedule,100% of bcbs custom fee schedule,38.12,100,,,fee schedule,100% of bcbs custom fee schedule,42.31,111,,,fee schedule,111% of bcbs custom fee schedule,63.75,50,,51,percent of total billed charges,50% of total billed charges,89.25,70,,71.4,percent of total billed charges,70% of total billed charges,61.81,48.48,,49.448,percent of total billed charges,48.48% of total billed charges,12.71,101,,,fee schedule,101% of cms custom fee schedule,61.81,48.48,,49.448,percent of total billed charges,48.48% of total billed charges,89.25,70,,71.4,percent of total billed charges,70% of total billed charges,89.25,70,,71.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,61.81,48.48,,49.448,percent of total billed charges,48.48% of total billed charges,114.75,90,,91.8,percent of total billed charges,90% of total billed charges,48.48,114.75,
HEPATITIS A TOTAL ANTIBODIES,,,300,RC,86708,HCPCS,outpatient,,,36,21.60,,21.6,60,,17.28,percent of total billed charges,60% of total billed charges,17.28,48,,13.824,percent of total billed charges,48% of total billed charges,35.24,100,,,fee schedule,100% of bcbs custom fee schedule,35.24,100,,,fee schedule,100% of bcbs custom fee schedule,39.12,111,,,fee schedule,111% of bcbs custom fee schedule,18,50,,14.4,percent of total billed charges,50% of total billed charges,25.2,70,,20.16,percent of total billed charges,70% of total billed charges,17.45,48.48,,13.96,percent of total billed charges,48.48% of total billed charges,12.51,101,,,fee schedule,101% of cms custom fee schedule,17.45,48.48,,13.96,percent of total billed charges,48.48% of total billed charges,25.2,70,,20.16,percent of total billed charges,70% of total billed charges,25.2,70,,20.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,17.45,48.48,,13.96,percent of total billed charges,48.48% of total billed charges,32.4,90,,25.92,percent of total billed charges,90% of total billed charges,17.45,90,
NEPHELOMETRY,41000784,CDM,300,RC,83883,HCPCS,outpatient,,,115.5,69.30,,69.3,60,,55.44,percent of total billed charges,60% of total billed charges,55.44,48,,44.352,percent of total billed charges,48% of total billed charges,14.08,100,,,fee schedule,100% of bcbs custom fee schedule,14.08,100,,,fee schedule,100% of bcbs custom fee schedule,15.63,111,,,fee schedule,111% of bcbs custom fee schedule,57.75,50,,46.2,percent of total billed charges,50% of total billed charges,80.85,70,,64.68,percent of total billed charges,70% of total billed charges,55.99,48.48,,44.792,percent of total billed charges,48.48% of total billed charges,13.74,101,,,fee schedule,101% of cms custom fee schedule,55.99,48.48,,44.792,percent of total billed charges,48.48% of total billed charges,80.85,70,,64.68,percent of total billed charges,70% of total billed charges,80.85,70,,64.68,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,55.99,48.48,,44.792,percent of total billed charges,48.48% of total billed charges,103.95,90,,83.16,percent of total billed charges,90% of total billed charges,48.48,103.95,
H.PYLORI ANTIBODIES,41000351,CDM,302,RC,86677,HCPCS,outpatient,,,87.5,52.50,QW,52.5,60,,42,percent of total billed charges,60% of total billed charges,42,48,,33.6,percent of total billed charges,48% of total billed charges,35.21,100,,,fee schedule,100% of bcbs custom fee schedule,35.21,100,,,fee schedule,100% of bcbs custom fee schedule,39.08,111,,,fee schedule,111% of bcbs custom fee schedule,43.75,50,,35,percent of total billed charges,50% of total billed charges,61.25,70,,49,percent of total billed charges,70% of total billed charges,42.42,48.48,,33.936,percent of total billed charges,48.48% of total billed charges,17.02,101,,,fee schedule,101% of cms custom fee schedule,42.42,48.48,,33.936,percent of total billed charges,48.48% of total billed charges,61.25,70,,49,percent of total billed charges,70% of total billed charges,61.25,70,,49,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,42.42,48.48,,33.936,percent of total billed charges,48.48% of total billed charges,78.75,90,,63,percent of total billed charges,90% of total billed charges,42.42,90,
APOLIPOPROTEIN,41001097,CDM,300,RC,82172,HCPCS,outpatient,,,119.5,71.70,91,71.7,60,,57.36,percent of total billed charges,60% of total billed charges,57.36,48,,45.888,percent of total billed charges,48% of total billed charges,46.93,100,,,fee schedule,100% of bcbs custom fee schedule,46.93,100,,,fee schedule,100% of bcbs custom fee schedule,52.09,111,,,fee schedule,111% of bcbs custom fee schedule,59.75,50,,47.8,percent of total billed charges,50% of total billed charges,83.65,70,,66.92,percent of total billed charges,70% of total billed charges,57.93,48.48,,46.344,percent of total billed charges,48.48% of total billed charges,21.3,101,,,fee schedule,101% of cms custom fee schedule,57.93,48.48,,46.344,percent of total billed charges,48.48% of total billed charges,83.65,70,,66.92,percent of total billed charges,70% of total billed charges,83.65,70,,66.92,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,57.93,48.48,,46.344,percent of total billed charges,48.48% of total billed charges,107.55,90,,86.04,percent of total billed charges,90% of total billed charges,48.48,107.55,
BILIRUBIN DIRECT,41000020,CDM,301,RC,82248,HCPCS,outpatient,,,51.25,30.75,,30.75,60,,24.6,percent of total billed charges,60% of total billed charges,24.6,48,,19.68,percent of total billed charges,48% of total billed charges,10.55,100,,,fee schedule,100% of bcbs custom fee schedule,10.55,100,,,fee schedule,100% of bcbs custom fee schedule,11.71,111,,,fee schedule,111% of bcbs custom fee schedule,25.63,50,,20.504,percent of total billed charges,50% of total billed charges,35.88,70,,28.704,percent of total billed charges,70% of total billed charges,24.85,48.48,,19.88,percent of total billed charges,48.48% of total billed charges,5.07,101,,,fee schedule,101% of cms custom fee schedule,24.85,48.48,,19.88,percent of total billed charges,48.48% of total billed charges,35.88,70,,28.704,percent of total billed charges,70% of total billed charges,35.88,70,,28.704,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,24.85,48.48,,19.88,percent of total billed charges,48.48% of total billed charges,46.13,90,,36.904,percent of total billed charges,90% of total billed charges,24.85,90,
AMPHETAMINES CONFIRMATION,,,300,RC,80324,HCPCS,outpatient,,,62.5,37.50,,37.5,60,,30,percent of total billed charges,60% of total billed charges,30,48,,24,percent of total billed charges,48% of total billed charges,14.1,100,,,fee schedule,100% of bcbs custom fee schedule,14.1,100,,,fee schedule,100% of bcbs custom fee schedule,15.65,111,,,fee schedule,111% of bcbs custom fee schedule,31.25,50,,25,percent of total billed charges,50% of total billed charges,43.75,70,,35,percent of total billed charges,70% of total billed charges,30.3,48.48,,24.24,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,30.3,48.48,,24.24,percent of total billed charges,48.48% of total billed charges,43.75,70,,35,percent of total billed charges,70% of total billed charges,43.75,70,,35,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,30.3,48.48,,24.24,percent of total billed charges,48.48% of total billed charges,56.25,90,,45,percent of total billed charges,90% of total billed charges,30.3,90,
COCAINE CONFIRMATION,,,300,RC,80353,HCPCS,outpatient,,,62.5,37.50,,37.5,60,,30,percent of total billed charges,60% of total billed charges,30,48,,24,percent of total billed charges,48% of total billed charges,13.78,100,,,fee schedule,100% of bcbs custom fee schedule,13.78,100,,,fee schedule,100% of bcbs custom fee schedule,15.3,111,,,fee schedule,111% of bcbs custom fee schedule,31.25,50,,25,percent of total billed charges,50% of total billed charges,43.75,70,,35,percent of total billed charges,70% of total billed charges,30.3,48.48,,24.24,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,30.3,48.48,,24.24,percent of total billed charges,48.48% of total billed charges,43.75,70,,35,percent of total billed charges,70% of total billed charges,43.75,70,,35,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,30.3,48.48,,24.24,percent of total billed charges,48.48% of total billed charges,56.25,90,,45,percent of total billed charges,90% of total billed charges,30.3,90,
METHADONE CONFIRMATION,,,300,RC,80358,HCPCS,outpatient,,,62.5,37.50,,37.5,60,,30,percent of total billed charges,60% of total billed charges,30,48,,24,percent of total billed charges,48% of total billed charges,14.83,100,,,fee schedule,100% of bcbs custom fee schedule,14.83,100,,,fee schedule,100% of bcbs custom fee schedule,16.46,111,,,fee schedule,111% of bcbs custom fee schedule,31.25,50,,25,percent of total billed charges,50% of total billed charges,43.75,70,,35,percent of total billed charges,70% of total billed charges,30.3,48.48,,24.24,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,30.3,48.48,,24.24,percent of total billed charges,48.48% of total billed charges,43.75,70,,35,percent of total billed charges,70% of total billed charges,43.75,70,,35,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,30.3,48.48,,24.24,percent of total billed charges,48.48% of total billed charges,56.25,90,,45,percent of total billed charges,90% of total billed charges,30.3,90,
ANTIBODY SCREEN,41040301,CDM,300,RC,86850,HCPCS,outpatient,,,143.75,86.25,,86.25,60,,69,percent of total billed charges,60% of total billed charges,69,48,,55.2,percent of total billed charges,48% of total billed charges,20.64,100,,,fee schedule,100% of bcbs custom fee schedule,20.64,100,,,fee schedule,100% of bcbs custom fee schedule,22.91,111,,,fee schedule,111% of bcbs custom fee schedule,71.88,50,,57.504,percent of total billed charges,50% of total billed charges,100.63,70,,80.504,percent of total billed charges,70% of total billed charges,69.69,48.48,,55.752,percent of total billed charges,48.48% of total billed charges,9.87,101,,,fee schedule,101% of cms custom fee schedule,69.69,48.48,,55.752,percent of total billed charges,48.48% of total billed charges,100.63,70,,80.504,percent of total billed charges,70% of total billed charges,100.63,70,,80.504,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,69.69,48.48,,55.752,percent of total billed charges,48.48% of total billed charges,129.38,90,,103.504,percent of total billed charges,90% of total billed charges,48.48,129.38,
BARTONELLA ANTIBODIES,41001218,CDM,300,RC,86611,HCPCS,outpatient,,,97.5,58.50,91,58.5,60,,46.8,percent of total billed charges,60% of total billed charges,46.8,48,,37.44,percent of total billed charges,48% of total billed charges,30.83,100,,,fee schedule,100% of bcbs custom fee schedule,30.83,100,,,fee schedule,100% of bcbs custom fee schedule,34.22,111,,,fee schedule,111% of bcbs custom fee schedule,48.75,50,,39,percent of total billed charges,50% of total billed charges,68.25,70,,54.6,percent of total billed charges,70% of total billed charges,47.27,48.48,,37.816,percent of total billed charges,48.48% of total billed charges,10.28,101,,,fee schedule,101% of cms custom fee schedule,47.27,48.48,,37.816,percent of total billed charges,48.48% of total billed charges,68.25,70,,54.6,percent of total billed charges,70% of total billed charges,68.25,70,,54.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,47.27,48.48,,37.816,percent of total billed charges,48.48% of total billed charges,87.75,90,,70.2,percent of total billed charges,90% of total billed charges,47.27,90,
TEGRETOL(CARBAMAZEPINE),41009048,CDM,301,RC,80156,HCPCS,outpatient,,,105,63.00,,63,60,,50.4,percent of total billed charges,60% of total billed charges,50.4,48,,40.32,percent of total billed charges,48% of total billed charges,35.24,100,,,fee schedule,100% of bcbs custom fee schedule,35.24,100,,,fee schedule,100% of bcbs custom fee schedule,39.12,111,,,fee schedule,111% of bcbs custom fee schedule,52.5,50,,42,percent of total billed charges,50% of total billed charges,73.5,70,,58.8,percent of total billed charges,70% of total billed charges,50.9,48.48,,40.72,percent of total billed charges,48.48% of total billed charges,14.72,101,,,fee schedule,101% of cms custom fee schedule,50.9,48.48,,40.72,percent of total billed charges,48.48% of total billed charges,73.5,70,,58.8,percent of total billed charges,70% of total billed charges,73.5,70,,58.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,50.9,48.48,,40.72,percent of total billed charges,48.48% of total billed charges,94.5,90,,75.6,percent of total billed charges,90% of total billed charges,48.48,94.5,
LIPOPROTEIN A,41009100,CDM,300,RC,83695,HCPCS,outpatient,,,110,66.00,,66,60,,52.8,percent of total billed charges,60% of total billed charges,52.8,48,,42.24,percent of total billed charges,48% of total billed charges,33.1,100,,,fee schedule,100% of bcbs custom fee schedule,33.1,100,,,fee schedule,100% of bcbs custom fee schedule,36.74,111,,,fee schedule,111% of bcbs custom fee schedule,55,50,,44,percent of total billed charges,50% of total billed charges,77,70,,61.6,percent of total billed charges,70% of total billed charges,53.33,48.48,,42.664,percent of total billed charges,48.48% of total billed charges,14.46,101,,,fee schedule,101% of cms custom fee schedule,53.33,48.48,,42.664,percent of total billed charges,48.48% of total billed charges,77,70,,61.6,percent of total billed charges,70% of total billed charges,77,70,,61.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,53.33,48.48,,42.664,percent of total billed charges,48.48% of total billed charges,99,90,,79.2,percent of total billed charges,90% of total billed charges,48.48,99,
B 6,41000334,CDM,300,RC,84207,HCPCS,outpatient,,,96.25,57.75,,57.75,60,,46.2,percent of total billed charges,60% of total billed charges,46.2,48,,36.96,percent of total billed charges,48% of total billed charges,42.81,100,,,fee schedule,100% of bcbs custom fee schedule,42.81,100,,,fee schedule,100% of bcbs custom fee schedule,47.52,111,,,fee schedule,111% of bcbs custom fee schedule,48.13,50,,38.504,percent of total billed charges,50% of total billed charges,67.38,70,,53.904,percent of total billed charges,70% of total billed charges,46.66,48.48,,37.328,percent of total billed charges,48.48% of total billed charges,28.38,101,,,fee schedule,101% of cms custom fee schedule,46.66,48.48,,37.328,percent of total billed charges,48.48% of total billed charges,67.38,70,,53.904,percent of total billed charges,70% of total billed charges,67.38,70,,53.904,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,46.66,48.48,,37.328,percent of total billed charges,48.48% of total billed charges,86.63,90,,69.304,percent of total billed charges,90% of total billed charges,46.66,90,
"OPIATES, CONFIRMATION",,,300,RC,80361,HCPCS,outpatient,,,62.5,37.50,,37.5,60,,30,percent of total billed charges,60% of total billed charges,30,48,,24,percent of total billed charges,48% of total billed charges,18.75,100,,,fee schedule,100% of bcbs custom fee schedule,18.75,100,,,fee schedule,100% of bcbs custom fee schedule,20.81,111,,,fee schedule,111% of bcbs custom fee schedule,31.25,50,,25,percent of total billed charges,50% of total billed charges,43.75,70,,35,percent of total billed charges,70% of total billed charges,30.3,48.48,,24.24,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,30.3,48.48,,24.24,percent of total billed charges,48.48% of total billed charges,43.75,70,,35,percent of total billed charges,70% of total billed charges,43.75,70,,35,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,30.3,48.48,,24.24,percent of total billed charges,48.48% of total billed charges,56.25,90,,45,percent of total billed charges,90% of total billed charges,30.3,90,
"DRUG SCREEN W/ COLLEC , CONTRACTED PRICE",,,300,RC,80307,HCPCS,outpatient,,,60,36.00,,36,60,,28.8,percent of total billed charges,60% of total billed charges,28.8,48,,23.04,percent of total billed charges,48% of total billed charges,145,100,,,fee schedule,100% of bcbs custom fee schedule,145,100,,,fee schedule,100% of bcbs custom fee schedule,160.95,111,,,fee schedule,111% of bcbs custom fee schedule,30,50,,24,percent of total billed charges,50% of total billed charges,42,70,,33.6,percent of total billed charges,70% of total billed charges,29.09,48.48,,23.272,percent of total billed charges,48.48% of total billed charges,62.76,101,,,fee schedule,101% of cms custom fee schedule,29.09,48.48,,23.272,percent of total billed charges,48.48% of total billed charges,42,70,,33.6,percent of total billed charges,70% of total billed charges,42,70,,33.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,29.09,48.48,,23.272,percent of total billed charges,48.48% of total billed charges,54,90,,43.2,percent of total billed charges,90% of total billed charges,29.09,90,
Pancreatic Elastase-1 Fecal,41000540,CDM,300,RC,83520,HCPCS,outpatient,,,230,138.00,,138,60,,110.4,percent of total billed charges,60% of total billed charges,110.4,48,,88.32,percent of total billed charges,48% of total billed charges,39.22,100,,,fee schedule,100% of bcbs custom fee schedule,39.22,100,,,fee schedule,100% of bcbs custom fee schedule,43.53,111,,,fee schedule,111% of bcbs custom fee schedule,115,50,,92,percent of total billed charges,50% of total billed charges,161,70,,128.8,percent of total billed charges,70% of total billed charges,111.5,48.48,,89.2,percent of total billed charges,48.48% of total billed charges,17.44,101,,,fee schedule,101% of cms custom fee schedule,111.5,48.48,,89.2,percent of total billed charges,48.48% of total billed charges,161,70,,128.8,percent of total billed charges,70% of total billed charges,161,70,,128.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,111.5,48.48,,89.2,percent of total billed charges,48.48% of total billed charges,207,90,,165.6,percent of total billed charges,90% of total billed charges,48.48,207,
IMMUNOASSAY ANALYTE QUANT RIA (PTHRP),41000095,CDM,300,RC,83519,HCPCS,outpatient,,,235,141.00,,141,60,,112.8,percent of total billed charges,60% of total billed charges,112.8,48,,90.24,percent of total billed charges,48% of total billed charges,14.1,100,,,fee schedule,100% of bcbs custom fee schedule,14.1,100,,,fee schedule,100% of bcbs custom fee schedule,15.65,111,,,fee schedule,111% of bcbs custom fee schedule,117.5,50,,94,percent of total billed charges,50% of total billed charges,164.5,70,,131.6,percent of total billed charges,70% of total billed charges,113.93,48.48,,91.144,percent of total billed charges,48.48% of total billed charges,18.58,101,,,fee schedule,101% of cms custom fee schedule,113.93,48.48,,91.144,percent of total billed charges,48.48% of total billed charges,164.5,70,,131.6,percent of total billed charges,70% of total billed charges,164.5,70,,131.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,113.93,48.48,,91.144,percent of total billed charges,48.48% of total billed charges,211.5,90,,169.2,percent of total billed charges,90% of total billed charges,48.48,211.5,
CYTOMEGALOVIRUS QUANT PCR,41001087,CDM,300,RC,87497,HCPCS,outpatient,,,282,169.20,,169.2,60,,135.36,percent of total billed charges,60% of total billed charges,135.36,48,,108.288,percent of total billed charges,48% of total billed charges,129.73,100,,,fee schedule,100% of bcbs custom fee schedule,129.73,100,,,fee schedule,100% of bcbs custom fee schedule,144,111,,,fee schedule,111% of bcbs custom fee schedule,141,50,,112.8,percent of total billed charges,50% of total billed charges,197.4,70,,157.92,percent of total billed charges,70% of total billed charges,136.71,48.48,,109.368,percent of total billed charges,48.48% of total billed charges,43.27,101,,,fee schedule,101% of cms custom fee schedule,136.71,48.48,,109.368,percent of total billed charges,48.48% of total billed charges,197.4,70,,157.92,percent of total billed charges,70% of total billed charges,197.4,70,,157.92,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,136.71,48.48,,109.368,percent of total billed charges,48.48% of total billed charges,253.8,90,,203.04,percent of total billed charges,90% of total billed charges,48.48,253.8,
OXCARBAZEPINE LEVEL,,,300,RC,80183,HCPCS,outpatient,,,173.75,104.25,,104.25,60,,83.4,percent of total billed charges,60% of total billed charges,83.4,48,,66.72,percent of total billed charges,48% of total billed charges,33.1,100,,,fee schedule,100% of bcbs custom fee schedule,33.1,100,,,fee schedule,100% of bcbs custom fee schedule,36.74,111,,,fee schedule,111% of bcbs custom fee schedule,86.88,50,,69.504,percent of total billed charges,50% of total billed charges,121.63,70,,97.304,percent of total billed charges,70% of total billed charges,84.23,48.48,,67.384,percent of total billed charges,48.48% of total billed charges,13.38,101,,,fee schedule,101% of cms custom fee schedule,84.23,48.48,,67.384,percent of total billed charges,48.48% of total billed charges,121.63,70,,97.304,percent of total billed charges,70% of total billed charges,121.63,70,,97.304,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,84.23,48.48,,67.384,percent of total billed charges,48.48% of total billed charges,156.38,90,,125.104,percent of total billed charges,90% of total billed charges,48.48,156.38,
"Allergen Specific Each, IgE",41000099,CDM,300,RC,86003,HCPCS,outpatient,,,35,21.00,91,21,60,,16.8,percent of total billed charges,60% of total billed charges,16.8,48,,13.44,percent of total billed charges,48% of total billed charges,15.82,100,,,fee schedule,100% of bcbs custom fee schedule,15.82,100,,,fee schedule,100% of bcbs custom fee schedule,17.56,111,,,fee schedule,111% of bcbs custom fee schedule,17.5,50,,14,percent of total billed charges,50% of total billed charges,24.5,70,,19.6,percent of total billed charges,70% of total billed charges,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,5.27,101,,,fee schedule,101% of cms custom fee schedule,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,24.5,70,,19.6,percent of total billed charges,70% of total billed charges,24.5,70,,19.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,31.5,90,,25.2,percent of total billed charges,90% of total billed charges,16.97,90,
DNA Collection Fee,,,300,RC,84999,HCPCS,outpatient,,,40,24.00,,24,60,,19.2,percent of total billed charges,60% of total billed charges,19.2,48,,15.36,percent of total billed charges,48% of total billed charges,7.16,100,,,fee schedule,100% of bcbs custom fee schedule,7.16,100,,,fee schedule,100% of bcbs custom fee schedule,7.95,111,,,fee schedule,111% of bcbs custom fee schedule,20,50,,16,percent of total billed charges,50% of total billed charges,28,70,,22.4,percent of total billed charges,70% of total billed charges,19.39,48.48,,15.512,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,19.39,48.48,,15.512,percent of total billed charges,48.48% of total billed charges,28,70,,22.4,percent of total billed charges,70% of total billed charges,28,70,,22.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,19.39,48.48,,15.512,percent of total billed charges,48.48% of total billed charges,36,90,,28.8,percent of total billed charges,90% of total billed charges,19.39,90,
PHENOBARBITAL,41009032,CDM,300,RC,80184,HCPCS,outpatient,,,129.5,77.70,,77.7,60,,62.16,percent of total billed charges,60% of total billed charges,62.16,48,,49.728,percent of total billed charges,48% of total billed charges,34.71,100,,,fee schedule,100% of bcbs custom fee schedule,34.71,100,,,fee schedule,100% of bcbs custom fee schedule,38.53,111,,,fee schedule,111% of bcbs custom fee schedule,64.75,50,,51.8,percent of total billed charges,50% of total billed charges,90.65,70,,72.52,percent of total billed charges,70% of total billed charges,62.78,48.48,,50.224,percent of total billed charges,48.48% of total billed charges,15.45,101,,,fee schedule,101% of cms custom fee schedule,62.78,48.48,,50.224,percent of total billed charges,48.48% of total billed charges,90.65,70,,72.52,percent of total billed charges,70% of total billed charges,90.65,70,,72.52,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,62.78,48.48,,50.224,percent of total billed charges,48.48% of total billed charges,116.55,90,,93.24,percent of total billed charges,90% of total billed charges,48.48,116.55,
"PROTEIN ELECTROPHORESIS, SERUM",41000300,CDM,300,RC,84165,HCPCS,outpatient,,,201.25,120.75,,120.75,60,,96.6,percent of total billed charges,60% of total billed charges,96.6,48,,77.28,percent of total billed charges,48% of total billed charges,32.53,100,,,fee schedule,100% of bcbs custom fee schedule,32.53,100,,,fee schedule,100% of bcbs custom fee schedule,36.11,111,,,fee schedule,111% of bcbs custom fee schedule,100.63,50,,80.504,percent of total billed charges,50% of total billed charges,140.88,70,,112.704,percent of total billed charges,70% of total billed charges,97.57,48.48,,78.056,percent of total billed charges,48.48% of total billed charges,10.85,101,,,fee schedule,101% of cms custom fee schedule,97.57,48.48,,78.056,percent of total billed charges,48.48% of total billed charges,140.88,70,,112.704,percent of total billed charges,70% of total billed charges,140.88,70,,112.704,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,97.57,48.48,,78.056,percent of total billed charges,48.48% of total billed charges,181.13,90,,144.904,percent of total billed charges,90% of total billed charges,48.48,181.13,
DILANTIN,41009029,CDM,301,RC,80185,HCPCS,outpatient,,,112,67.20,,67.2,60,,53.76,percent of total billed charges,60% of total billed charges,53.76,48,,43.008,percent of total billed charges,48% of total billed charges,40.15,100,,,fee schedule,100% of bcbs custom fee schedule,40.15,100,,,fee schedule,100% of bcbs custom fee schedule,44.57,111,,,fee schedule,111% of bcbs custom fee schedule,56,50,,44.8,percent of total billed charges,50% of total billed charges,78.4,70,,62.72,percent of total billed charges,70% of total billed charges,54.3,48.48,,43.44,percent of total billed charges,48.48% of total billed charges,13.38,101,,,fee schedule,101% of cms custom fee schedule,54.3,48.48,,43.44,percent of total billed charges,48.48% of total billed charges,78.4,70,,62.72,percent of total billed charges,70% of total billed charges,78.4,70,,62.72,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,54.3,48.48,,43.44,percent of total billed charges,48.48% of total billed charges,100.8,90,,80.64,percent of total billed charges,90% of total billed charges,48.48,100.8,
IODINE LEVEL,41001044,CDM,300,RC,82542,HCPCS,outpatient,,,141.25,84.75,,84.75,60,,67.8,percent of total billed charges,60% of total billed charges,67.8,48,,54.24,percent of total billed charges,48% of total billed charges,54.69,100,,,fee schedule,100% of bcbs custom fee schedule,54.69,100,,,fee schedule,100% of bcbs custom fee schedule,60.71,111,,,fee schedule,111% of bcbs custom fee schedule,70.63,50,,56.504,percent of total billed charges,50% of total billed charges,98.88,70,,79.104,percent of total billed charges,70% of total billed charges,68.48,48.48,,54.784,percent of total billed charges,48.48% of total billed charges,24.33,101,,,fee schedule,101% of cms custom fee schedule,68.48,48.48,,54.784,percent of total billed charges,48.48% of total billed charges,98.88,70,,79.104,percent of total billed charges,70% of total billed charges,98.88,70,,79.104,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,68.48,48.48,,54.784,percent of total billed charges,48.48% of total billed charges,127.13,90,,101.704,percent of total billed charges,90% of total billed charges,48.48,127.13,
THEOPHYLLINE (THEO-DUR),41000455,CDM,300,RC,80198,HCPCS,outpatient,,,140,84.00,,84,60,,67.2,percent of total billed charges,60% of total billed charges,67.2,48,,53.76,percent of total billed charges,48% of total billed charges,42.86,100,,,fee schedule,100% of bcbs custom fee schedule,42.86,100,,,fee schedule,100% of bcbs custom fee schedule,47.57,111,,,fee schedule,111% of bcbs custom fee schedule,70,50,,56,percent of total billed charges,50% of total billed charges,98,70,,78.4,percent of total billed charges,70% of total billed charges,67.87,48.48,,54.296,percent of total billed charges,48.48% of total billed charges,14.28,101,,,fee schedule,101% of cms custom fee schedule,67.87,48.48,,54.296,percent of total billed charges,48.48% of total billed charges,98,70,,78.4,percent of total billed charges,70% of total billed charges,98,70,,78.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,67.87,48.48,,54.296,percent of total billed charges,48.48% of total billed charges,126,90,,100.8,percent of total billed charges,90% of total billed charges,48.48,126,
TOBRAMYCIN LEVEL,41000166,CDM,300,RC,80200,HCPCS,outpatient,,,137,82.20,,82.2,60,,65.76,percent of total billed charges,60% of total billed charges,65.76,48,,52.608,percent of total billed charges,48% of total billed charges,35.24,100,,,fee schedule,100% of bcbs custom fee schedule,35.24,100,,,fee schedule,100% of bcbs custom fee schedule,39.12,111,,,fee schedule,111% of bcbs custom fee schedule,68.5,50,,54.8,percent of total billed charges,50% of total billed charges,95.9,70,,76.72,percent of total billed charges,70% of total billed charges,66.42,48.48,,53.136,percent of total billed charges,48.48% of total billed charges,16.29,101,,,fee schedule,101% of cms custom fee schedule,66.42,48.48,,53.136,percent of total billed charges,48.48% of total billed charges,95.9,70,,76.72,percent of total billed charges,70% of total billed charges,95.9,70,,76.72,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,66.42,48.48,,53.136,percent of total billed charges,48.48% of total billed charges,123.3,90,,98.64,percent of total billed charges,90% of total billed charges,48.48,123.3,
TRICYCLIC ANTIDEPRESSANT QUANT,,,300,RC,80335,HCPCS,outpatient,,,108,64.80,,64.8,60,,51.84,percent of total billed charges,60% of total billed charges,51.84,48,,41.472,percent of total billed charges,48% of total billed charges,16.26,100,,,fee schedule,100% of bcbs custom fee schedule,16.26,100,,,fee schedule,100% of bcbs custom fee schedule,18.05,111,,,fee schedule,111% of bcbs custom fee schedule,54,50,,43.2,percent of total billed charges,50% of total billed charges,75.6,70,,60.48,percent of total billed charges,70% of total billed charges,52.36,48.48,,41.888,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,52.36,48.48,,41.888,percent of total billed charges,48.48% of total billed charges,75.6,70,,60.48,percent of total billed charges,70% of total billed charges,75.6,70,,60.48,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,52.36,48.48,,41.888,percent of total billed charges,48.48% of total billed charges,97.2,90,,77.76,percent of total billed charges,90% of total billed charges,48.48,97.2,
EPSTEIN BARR VIRUS VCA IGG,41000273,CDM,300,RC,86665,HCPCS,outpatient,,,135,81.00,,81,60,,64.8,percent of total billed charges,60% of total billed charges,64.8,48,,51.84,percent of total billed charges,48% of total billed charges,53.99,100,,,fee schedule,100% of bcbs custom fee schedule,53.99,100,,,fee schedule,100% of bcbs custom fee schedule,59.93,111,,,fee schedule,111% of bcbs custom fee schedule,67.5,50,,54,percent of total billed charges,50% of total billed charges,94.5,70,,75.6,percent of total billed charges,70% of total billed charges,65.45,48.48,,52.36,percent of total billed charges,48.48% of total billed charges,18.32,101,,,fee schedule,101% of cms custom fee schedule,65.45,48.48,,52.36,percent of total billed charges,48.48% of total billed charges,94.5,70,,75.6,percent of total billed charges,70% of total billed charges,94.5,70,,75.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,65.45,48.48,,52.36,percent of total billed charges,48.48% of total billed charges,121.5,90,,97.2,percent of total billed charges,90% of total billed charges,48.48,121.5,
URINALYSIS AUTO W/O SCOPE,41000413,CDM,307,RC,81003,HCPCS,outpatient,,,36.25,21.75,,21.75,60,,17.4,percent of total billed charges,60% of total billed charges,17.4,48,,13.92,percent of total billed charges,48% of total billed charges,6.81,100,,,fee schedule,100% of bcbs custom fee schedule,6.81,100,,,fee schedule,100% of bcbs custom fee schedule,7.56,111,,,fee schedule,111% of bcbs custom fee schedule,18.13,50,,14.504,percent of total billed charges,50% of total billed charges,25.38,70,,20.304,percent of total billed charges,70% of total billed charges,17.57,48.48,,14.056,percent of total billed charges,48.48% of total billed charges,2.27,101,,,fee schedule,101% of cms custom fee schedule,17.57,48.48,,14.056,percent of total billed charges,48.48% of total billed charges,25.38,70,,20.304,percent of total billed charges,70% of total billed charges,25.38,70,,20.304,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,17.57,48.48,,14.056,percent of total billed charges,48.48% of total billed charges,32.63,90,,26.104,percent of total billed charges,90% of total billed charges,17.57,90,
Quantiferon-TB Gold,41001135,CDM,300,RC,86480,HCPCS,outpatient,,,320,192.00,,192,60,,153.6,percent of total billed charges,60% of total billed charges,153.6,48,,122.88,percent of total billed charges,48% of total billed charges,158.43,100,,,fee schedule,100% of bcbs custom fee schedule,158.43,100,,,fee schedule,100% of bcbs custom fee schedule,175.86,111,,,fee schedule,111% of bcbs custom fee schedule,160,50,,128,percent of total billed charges,50% of total billed charges,224,70,,179.2,percent of total billed charges,70% of total billed charges,155.14,48.48,,124.112,percent of total billed charges,48.48% of total billed charges,62.6,101,,,fee schedule,101% of cms custom fee schedule,155.14,48.48,,124.112,percent of total billed charges,48.48% of total billed charges,224,70,,179.2,percent of total billed charges,70% of total billed charges,224,70,,179.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,155.14,48.48,,124.112,percent of total billed charges,48.48% of total billed charges,288,90,,230.4,percent of total billed charges,90% of total billed charges,48.48,288,
URINALYSIS AUTO W/ MICRO,41000402,CDM,307,RC,81001,HCPCS,outpatient,,,68.75,41.25,,41.25,60,,33,percent of total billed charges,60% of total billed charges,33,48,,26.4,percent of total billed charges,48% of total billed charges,9.6,100,,,fee schedule,100% of bcbs custom fee schedule,9.6,100,,,fee schedule,100% of bcbs custom fee schedule,10.66,111,,,fee schedule,111% of bcbs custom fee schedule,34.38,50,,27.504,percent of total billed charges,50% of total billed charges,48.13,70,,38.504,percent of total billed charges,70% of total billed charges,33.33,48.48,,26.664,percent of total billed charges,48.48% of total billed charges,3.2,101,,,fee schedule,101% of cms custom fee schedule,33.33,48.48,,26.664,percent of total billed charges,48.48% of total billed charges,48.13,70,,38.504,percent of total billed charges,70% of total billed charges,48.13,70,,38.504,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,33.33,48.48,,26.664,percent of total billed charges,48.48% of total billed charges,61.88,90,,49.504,percent of total billed charges,90% of total billed charges,33.33,90,
BARBITURATES CONFIRMATION,,,300,RC,80345,HCPCS,outpatient,,,62.5,37.50,,37.5,60,,30,percent of total billed charges,60% of total billed charges,30,48,,24,percent of total billed charges,48% of total billed charges,10.4,100,,,fee schedule,100% of bcbs custom fee schedule,10.4,100,,,fee schedule,100% of bcbs custom fee schedule,11.54,111,,,fee schedule,111% of bcbs custom fee schedule,31.25,50,,25,percent of total billed charges,50% of total billed charges,43.75,70,,35,percent of total billed charges,70% of total billed charges,30.3,48.48,,24.24,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,30.3,48.48,,24.24,percent of total billed charges,48.48% of total billed charges,43.75,70,,35,percent of total billed charges,70% of total billed charges,43.75,70,,35,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,30.3,48.48,,24.24,percent of total billed charges,48.48% of total billed charges,56.25,90,,45,percent of total billed charges,90% of total billed charges,30.3,90,
URINE PREGNANCY TEST,41000905,CDM,307,RC,81025,HCPCS,outpatient,,,87.5,52.50,,52.5,60,,42,percent of total billed charges,60% of total billed charges,42,48,,33.6,percent of total billed charges,48% of total billed charges,19.16,100,,,fee schedule,100% of bcbs custom fee schedule,19.16,100,,,fee schedule,100% of bcbs custom fee schedule,21.27,111,,,fee schedule,111% of bcbs custom fee schedule,43.75,50,,35,percent of total billed charges,50% of total billed charges,61.25,70,,49,percent of total billed charges,70% of total billed charges,42.42,48.48,,33.936,percent of total billed charges,48.48% of total billed charges,8.7,101,,,fee schedule,101% of cms custom fee schedule,42.42,48.48,,33.936,percent of total billed charges,48.48% of total billed charges,61.25,70,,49,percent of total billed charges,70% of total billed charges,61.25,70,,49,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,42.42,48.48,,33.936,percent of total billed charges,48.48% of total billed charges,78.75,90,,63,percent of total billed charges,90% of total billed charges,42.42,90,
ACETAMINOPHEN LEVEL,,,301,RC,80143,HCPCS,outpatient,,,125,75.00,,75,60,,60,percent of total billed charges,60% of total billed charges,60,48,,48,percent of total billed charges,48% of total billed charges,62.5,50,,50,percent of total billed charges,50% of total billed charges,62.5,50,,50,percent of total billed charges,50% of total billed charges,62.5,50,,50,percent of total billed charges,50% of total billed charges,62.5,50,,50,percent of total billed charges,50% of total billed charges,87.5,70,,70,percent of total billed charges,70% of total billed charges,60.6,48.48,,48.48,percent of total billed charges,48.48% of total billed charges,18.83,101,,,fee schedule,101% of cms custom fee schedule,60.6,48.48,,48.48,percent of total billed charges,48.48% of total billed charges,87.5,70,,70,percent of total billed charges,70% of total billed charges,87.5,70,,70,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,60.6,48.48,,48.48,percent of total billed charges,48.48% of total billed charges,112.5,90,,90,percent of total billed charges,90% of total billed charges,48.48,112.5,
"Alkaloids, not otherwise specified",,,300,RC,80323,HCPCS,outpatient,,,123,73.80,,73.8,60,,59.04,percent of total billed charges,60% of total billed charges,59.04,48,,47.232,percent of total billed charges,48% of total billed charges,21.52,100,,,fee schedule,100% of bcbs custom fee schedule,21.52,100,,,fee schedule,100% of bcbs custom fee schedule,23.89,111,,,fee schedule,111% of bcbs custom fee schedule,61.5,50,,49.2,percent of total billed charges,50% of total billed charges,86.1,70,,68.88,percent of total billed charges,70% of total billed charges,59.63,48.48,,47.704,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,59.63,48.48,,47.704,percent of total billed charges,48.48% of total billed charges,86.1,70,,68.88,percent of total billed charges,70% of total billed charges,86.1,70,,68.88,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,59.63,48.48,,47.704,percent of total billed charges,48.48% of total billed charges,110.7,90,,88.56,percent of total billed charges,90% of total billed charges,48.48,110.7,
MICROALBUMIN QUANT,41009113,CDM,301,RC,82044,HCPCS,outpatient,,,61.25,36.75,,36.75,60,,29.4,percent of total billed charges,60% of total billed charges,29.4,48,,23.52,percent of total billed charges,48% of total billed charges,9.22,100,,,fee schedule,100% of bcbs custom fee schedule,9.22,100,,,fee schedule,100% of bcbs custom fee schedule,10.23,111,,,fee schedule,111% of bcbs custom fee schedule,30.63,50,,24.504,percent of total billed charges,50% of total billed charges,42.88,70,,34.304,percent of total billed charges,70% of total billed charges,29.69,48.48,,23.752,percent of total billed charges,48.48% of total billed charges,6.29,101,,,fee schedule,101% of cms custom fee schedule,29.69,48.48,,23.752,percent of total billed charges,48.48% of total billed charges,42.88,70,,34.304,percent of total billed charges,70% of total billed charges,42.88,70,,34.304,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,29.69,48.48,,23.752,percent of total billed charges,48.48% of total billed charges,55.13,90,,44.104,percent of total billed charges,90% of total billed charges,29.69,90,
RISTOCETIN COFACTOR/VWF ACT,41000311,CDM,300,RC,85245,HCPCS,outpatient,,,200,120.00,,120,60,,96,percent of total billed charges,60% of total billed charges,96,48,,76.8,percent of total billed charges,48% of total billed charges,69.5,100,,,fee schedule,100% of bcbs custom fee schedule,69.5,100,,,fee schedule,100% of bcbs custom fee schedule,77.15,111,,,fee schedule,111% of bcbs custom fee schedule,100,50,,80,percent of total billed charges,50% of total billed charges,140,70,,112,percent of total billed charges,70% of total billed charges,96.96,48.48,,77.568,percent of total billed charges,48.48% of total billed charges,23.17,101,,,fee schedule,101% of cms custom fee schedule,96.96,48.48,,77.568,percent of total billed charges,48.48% of total billed charges,140,70,,112,percent of total billed charges,70% of total billed charges,140,70,,112,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,96.96,48.48,,77.568,percent of total billed charges,48.48% of total billed charges,180,90,,144,percent of total billed charges,90% of total billed charges,48.48,180,
BILIRUBIN TOTAL,41000019,CDM,300,RC,82247,HCPCS,outpatient,,,37.5,22.50,,22.5,60,,18,percent of total billed charges,60% of total billed charges,18,48,,14.4,percent of total billed charges,48% of total billed charges,10.55,100,,,fee schedule,100% of bcbs custom fee schedule,10.55,100,,,fee schedule,100% of bcbs custom fee schedule,11.71,111,,,fee schedule,111% of bcbs custom fee schedule,18.75,50,,15,percent of total billed charges,50% of total billed charges,26.25,70,,21,percent of total billed charges,70% of total billed charges,18.18,48.48,,14.544,percent of total billed charges,48.48% of total billed charges,5.07,101,,,fee schedule,101% of cms custom fee schedule,18.18,48.48,,14.544,percent of total billed charges,48.48% of total billed charges,26.25,70,,21,percent of total billed charges,70% of total billed charges,26.25,70,,21,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,18.18,48.48,,14.544,percent of total billed charges,48.48% of total billed charges,33.75,90,,27,percent of total billed charges,90% of total billed charges,18.18,90,
"SEROTONIN LEVEL, SERUM",41000045,CDM,300,RC,84260,HCPCS,outpatient,,,358.83,215.30,,215.3,60,,172.24,percent of total billed charges,60% of total billed charges,172.24,48,,137.792,percent of total billed charges,48% of total billed charges,93.82,100,,,fee schedule,100% of bcbs custom fee schedule,93.82,100,,,fee schedule,100% of bcbs custom fee schedule,104.14,111,,,fee schedule,111% of bcbs custom fee schedule,179.42,50,,143.536,percent of total billed charges,50% of total billed charges,251.18,70,,200.944,percent of total billed charges,70% of total billed charges,173.96,48.48,,139.168,percent of total billed charges,48.48% of total billed charges,31.29,101,,,fee schedule,101% of cms custom fee schedule,173.96,48.48,,139.168,percent of total billed charges,48.48% of total billed charges,251.18,70,,200.944,percent of total billed charges,70% of total billed charges,251.18,70,,200.944,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,173.96,48.48,,139.168,percent of total billed charges,48.48% of total billed charges,322.95,90,,258.36,percent of total billed charges,90% of total billed charges,48.48,322.95,
Alpha 1 Antitrypsin Quantitative,41000758,CDM,300,RC,82103,HCPCS,outpatient,,,125,75.00,,75,60,,60,percent of total billed charges,60% of total billed charges,60,48,,48,percent of total billed charges,48% of total billed charges,40.69,100,,,fee schedule,100% of bcbs custom fee schedule,40.69,100,,,fee schedule,100% of bcbs custom fee schedule,45.17,111,,,fee schedule,111% of bcbs custom fee schedule,62.5,50,,50,percent of total billed charges,50% of total billed charges,87.5,70,,70,percent of total billed charges,70% of total billed charges,60.6,48.48,,48.48,percent of total billed charges,48.48% of total billed charges,13.57,101,,,fee schedule,101% of cms custom fee schedule,60.6,48.48,,48.48,percent of total billed charges,48.48% of total billed charges,87.5,70,,70,percent of total billed charges,70% of total billed charges,87.5,70,,70,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,60.6,48.48,,48.48,percent of total billed charges,48.48% of total billed charges,112.5,90,,90,percent of total billed charges,90% of total billed charges,48.48,112.5,
GASTRIC OCCULT BLOOD,41000511,CDM,301,RC,82271,HCPCS,outpatient,,,18.75,11.25,,11.25,60,,9,percent of total billed charges,60% of total billed charges,9,48,,7.2,percent of total billed charges,48% of total billed charges,8.3,100,,,fee schedule,100% of bcbs custom fee schedule,8.3,100,,,fee schedule,100% of bcbs custom fee schedule,9.21,111,,,fee schedule,111% of bcbs custom fee schedule,9.38,50,,7.504,percent of total billed charges,50% of total billed charges,13.13,70,,10.504,percent of total billed charges,70% of total billed charges,9.09,48.48,,7.272,percent of total billed charges,48.48% of total billed charges,5.37,101,,,fee schedule,101% of cms custom fee schedule,9.09,48.48,,7.272,percent of total billed charges,48.48% of total billed charges,13.13,70,,10.504,percent of total billed charges,70% of total billed charges,13.13,70,,10.504,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.09,48.48,,7.272,percent of total billed charges,48.48% of total billed charges,16.88,90,,13.504,percent of total billed charges,90% of total billed charges,9.09,90,
SEROTYPING ID,,,300,RC,87147,HCPCS,outpatient,,,30,18.00,,18,60,,14.4,percent of total billed charges,60% of total billed charges,14.4,48,,11.52,percent of total billed charges,48% of total billed charges,13,100,,,fee schedule,100% of bcbs custom fee schedule,13,100,,,fee schedule,100% of bcbs custom fee schedule,14.43,111,,,fee schedule,111% of bcbs custom fee schedule,15,50,,12,percent of total billed charges,50% of total billed charges,21,70,,16.8,percent of total billed charges,70% of total billed charges,14.54,48.48,,11.632,percent of total billed charges,48.48% of total billed charges,5.23,101,,,fee schedule,101% of cms custom fee schedule,14.54,48.48,,11.632,percent of total billed charges,48.48% of total billed charges,21,70,,16.8,percent of total billed charges,70% of total billed charges,21,70,,16.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,14.54,48.48,,11.632,percent of total billed charges,48.48% of total billed charges,27,90,,21.6,percent of total billed charges,90% of total billed charges,14.54,90,
MRSA/MSSA MR-STAPH DNA PROBE,,,300,RC,87641,HCPCS,outpatient,,,50,30.00,,30,60,,24,percent of total billed charges,60% of total billed charges,24,48,,19.2,percent of total billed charges,48% of total billed charges,89.72,100,,,fee schedule,100% of bcbs custom fee schedule,89.72,100,,,fee schedule,100% of bcbs custom fee schedule,99.59,111,,,fee schedule,111% of bcbs custom fee schedule,25,50,,20,percent of total billed charges,50% of total billed charges,35,70,,28,percent of total billed charges,70% of total billed charges,24.24,48.48,,19.392,percent of total billed charges,48.48% of total billed charges,35.44,101,,,fee schedule,101% of cms custom fee schedule,24.24,48.48,,19.392,percent of total billed charges,48.48% of total billed charges,35,70,,28,percent of total billed charges,70% of total billed charges,35,70,,28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,24.24,48.48,,19.392,percent of total billed charges,48.48% of total billed charges,45,90,,36,percent of total billed charges,90% of total billed charges,24.24,90,
MRSA/MSSA STAPH A DNA PROBE,,,300,RC,87640,HCPCS,outpatient,,,50,30.00,,30,60,,24,percent of total billed charges,60% of total billed charges,24,48,,19.2,percent of total billed charges,48% of total billed charges,89.72,100,,,fee schedule,100% of bcbs custom fee schedule,89.72,100,,,fee schedule,100% of bcbs custom fee schedule,99.59,111,,,fee schedule,111% of bcbs custom fee schedule,25,50,,20,percent of total billed charges,50% of total billed charges,35,70,,28,percent of total billed charges,70% of total billed charges,24.24,48.48,,19.392,percent of total billed charges,48.48% of total billed charges,35.44,101,,,fee schedule,101% of cms custom fee schedule,24.24,48.48,,19.392,percent of total billed charges,48.48% of total billed charges,35,70,,28,percent of total billed charges,70% of total billed charges,35,70,,28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,24.24,48.48,,19.392,percent of total billed charges,48.48% of total billed charges,45,90,,36,percent of total billed charges,90% of total billed charges,24.24,90,
HEPATITIS CORE ANTIBODY TOTAL,41000217,CDM,300,RC,86704,HCPCS,outpatient,,,150,90.00,,90,60,,72,percent of total billed charges,60% of total billed charges,72,48,,57.6,percent of total billed charges,48% of total billed charges,36.51,100,,,fee schedule,100% of bcbs custom fee schedule,36.51,100,,,fee schedule,100% of bcbs custom fee schedule,40.53,111,,,fee schedule,111% of bcbs custom fee schedule,75,50,,60,percent of total billed charges,50% of total billed charges,105,70,,84,percent of total billed charges,70% of total billed charges,72.72,48.48,,58.176,percent of total billed charges,48.48% of total billed charges,12.17,101,,,fee schedule,101% of cms custom fee schedule,72.72,48.48,,58.176,percent of total billed charges,48.48% of total billed charges,105,70,,84,percent of total billed charges,70% of total billed charges,105,70,,84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,72.72,48.48,,58.176,percent of total billed charges,48.48% of total billed charges,135,90,,108,percent of total billed charges,90% of total billed charges,48.48,135,
"PORPHOBILINOGEN, URINE",41000460,CDM,300,RC,84110,HCPCS,outpatient,,,90,54.00,,54,60,,43.2,percent of total billed charges,60% of total billed charges,43.2,48,,34.56,percent of total billed charges,48% of total billed charges,14.92,100,,,fee schedule,100% of bcbs custom fee schedule,14.92,100,,,fee schedule,100% of bcbs custom fee schedule,16.56,111,,,fee schedule,111% of bcbs custom fee schedule,45,50,,36,percent of total billed charges,50% of total billed charges,63,70,,50.4,percent of total billed charges,70% of total billed charges,43.63,48.48,,34.904,percent of total billed charges,48.48% of total billed charges,8.52,101,,,fee schedule,101% of cms custom fee schedule,43.63,48.48,,34.904,percent of total billed charges,48.48% of total billed charges,63,70,,50.4,percent of total billed charges,70% of total billed charges,63,70,,50.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,43.63,48.48,,34.904,percent of total billed charges,48.48% of total billed charges,81,90,,64.8,percent of total billed charges,90% of total billed charges,43.63,90,
ESTROGEN (TOTAL),41000465,CDM,300,RC,82672,HCPCS,outpatient,,,112.5,67.50,,67.5,60,,54,percent of total billed charges,60% of total billed charges,54,48,,43.2,percent of total billed charges,48% of total billed charges,65.68,100,,,fee schedule,100% of bcbs custom fee schedule,65.68,100,,,fee schedule,100% of bcbs custom fee schedule,72.9,111,,,fee schedule,111% of bcbs custom fee schedule,56.25,50,,45,percent of total billed charges,50% of total billed charges,78.75,70,,63,percent of total billed charges,70% of total billed charges,54.54,48.48,,43.632,percent of total billed charges,48.48% of total billed charges,21.92,101,,,fee schedule,101% of cms custom fee schedule,54.54,48.48,,43.632,percent of total billed charges,48.48% of total billed charges,78.75,70,,63,percent of total billed charges,70% of total billed charges,78.75,70,,63,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,54.54,48.48,,43.632,percent of total billed charges,48.48% of total billed charges,101.25,90,,81,percent of total billed charges,90% of total billed charges,48.48,101.25,
G6PD,41001170,CDM,300,RC,82955,HCPCS,outpatient,,,62.5,37.50,,37.5,60,,30,percent of total billed charges,60% of total billed charges,30,48,,24,percent of total billed charges,48% of total billed charges,29.37,100,,,fee schedule,100% of bcbs custom fee schedule,29.37,100,,,fee schedule,100% of bcbs custom fee schedule,32.6,111,,,fee schedule,111% of bcbs custom fee schedule,31.25,50,,25,percent of total billed charges,50% of total billed charges,43.75,70,,35,percent of total billed charges,70% of total billed charges,30.3,48.48,,24.24,percent of total billed charges,48.48% of total billed charges,9.8,101,,,fee schedule,101% of cms custom fee schedule,30.3,48.48,,24.24,percent of total billed charges,48.48% of total billed charges,43.75,70,,35,percent of total billed charges,70% of total billed charges,43.75,70,,35,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,30.3,48.48,,24.24,percent of total billed charges,48.48% of total billed charges,56.25,90,,45,percent of total billed charges,90% of total billed charges,30.3,90,
"Quantitation of Therapeutic Drug, unlist",41000125,CDM,300,RC,80299,HCPCS,outpatient,,,235,141.00,,141,60,,112.8,percent of total billed charges,60% of total billed charges,112.8,48,,90.24,percent of total billed charges,48% of total billed charges,41.48,100,,,fee schedule,100% of bcbs custom fee schedule,41.48,100,,,fee schedule,100% of bcbs custom fee schedule,46.04,111,,,fee schedule,111% of bcbs custom fee schedule,117.5,50,,94,percent of total billed charges,50% of total billed charges,164.5,70,,131.6,percent of total billed charges,70% of total billed charges,113.93,48.48,,91.144,percent of total billed charges,48.48% of total billed charges,18.83,101,,,fee schedule,101% of cms custom fee schedule,113.93,48.48,,91.144,percent of total billed charges,48.48% of total billed charges,164.5,70,,131.6,percent of total billed charges,70% of total billed charges,164.5,70,,131.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,113.93,48.48,,91.144,percent of total billed charges,48.48% of total billed charges,211.5,90,,169.2,percent of total billed charges,90% of total billed charges,48.48,211.5,
Tryptase IgE Quantitative,41000540,CDM,300,RC,83520,HCPCS,outpatient,,,180,108.00,,108,60,,86.4,percent of total billed charges,60% of total billed charges,86.4,48,,69.12,percent of total billed charges,48% of total billed charges,39.22,100,,,fee schedule,100% of bcbs custom fee schedule,39.22,100,,,fee schedule,100% of bcbs custom fee schedule,43.53,111,,,fee schedule,111% of bcbs custom fee schedule,90,50,,72,percent of total billed charges,50% of total billed charges,126,70,,100.8,percent of total billed charges,70% of total billed charges,87.26,48.48,,69.808,percent of total billed charges,48.48% of total billed charges,17.44,101,,,fee schedule,101% of cms custom fee schedule,87.26,48.48,,69.808,percent of total billed charges,48.48% of total billed charges,126,70,,100.8,percent of total billed charges,70% of total billed charges,126,70,,100.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,87.26,48.48,,69.808,percent of total billed charges,48.48% of total billed charges,162,90,,129.6,percent of total billed charges,90% of total billed charges,48.48,162,
"Alpha-GAL IgE, Serum",,,300,RC,86008,HCPCS,outpatient,,,170,102.00,,102,60,,81.6,percent of total billed charges,60% of total billed charges,81.6,48,,65.28,percent of total billed charges,48% of total billed charges,40.51,100,,,fee schedule,100% of bcbs custom fee schedule,40.51,100,,,fee schedule,100% of bcbs custom fee schedule,44.97,111,,,fee schedule,111% of bcbs custom fee schedule,85,50,,68,percent of total billed charges,50% of total billed charges,119,70,,95.2,percent of total billed charges,70% of total billed charges,82.42,48.48,,65.936,percent of total billed charges,48.48% of total billed charges,18.11,101,,,fee schedule,101% of cms custom fee schedule,82.42,48.48,,65.936,percent of total billed charges,48.48% of total billed charges,119,70,,95.2,percent of total billed charges,70% of total billed charges,119,70,,95.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,82.42,48.48,,65.936,percent of total billed charges,48.48% of total billed charges,153,90,,122.4,percent of total billed charges,90% of total billed charges,48.48,153,
HGB CHROMATOGRAPHY,,,300,RC,83021,HCPCS,outpatient,,,122.5,73.50,,73.5,60,,58.8,percent of total billed charges,60% of total billed charges,58.8,48,,47.04,percent of total billed charges,48% of total billed charges,54.69,100,,,fee schedule,100% of bcbs custom fee schedule,54.69,100,,,fee schedule,100% of bcbs custom fee schedule,60.71,111,,,fee schedule,111% of bcbs custom fee schedule,61.25,50,,49,percent of total billed charges,50% of total billed charges,85.75,70,,68.6,percent of total billed charges,70% of total billed charges,59.39,48.48,,47.512,percent of total billed charges,48.48% of total billed charges,18.24,101,,,fee schedule,101% of cms custom fee schedule,59.39,48.48,,47.512,percent of total billed charges,48.48% of total billed charges,85.75,70,,68.6,percent of total billed charges,70% of total billed charges,85.75,70,,68.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,59.39,48.48,,47.512,percent of total billed charges,48.48% of total billed charges,110.25,90,,88.2,percent of total billed charges,90% of total billed charges,48.48,110.25,
HOMOCYSTEINE,41000288,CDM,300,RC,83090,HCPCS,outpatient,,,158.5,95.10,,95.1,60,,76.08,percent of total billed charges,60% of total billed charges,76.08,48,,60.864,percent of total billed charges,48% of total billed charges,51.09,100,,,fee schedule,100% of bcbs custom fee schedule,51.09,100,,,fee schedule,100% of bcbs custom fee schedule,56.71,111,,,fee schedule,111% of bcbs custom fee schedule,79.25,50,,63.4,percent of total billed charges,50% of total billed charges,110.95,70,,88.76,percent of total billed charges,70% of total billed charges,76.84,48.48,,61.472,percent of total billed charges,48.48% of total billed charges,18.1,101,,,fee schedule,101% of cms custom fee schedule,76.84,48.48,,61.472,percent of total billed charges,48.48% of total billed charges,110.95,70,,88.76,percent of total billed charges,70% of total billed charges,110.95,70,,88.76,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,76.84,48.48,,61.472,percent of total billed charges,48.48% of total billed charges,142.65,90,,114.12,percent of total billed charges,90% of total billed charges,48.48,142.65,
CHOLESTEROL HDL,41009042,CDM,301,RC,83718,HCPCS,outpatient,,,93.5,56.10,,56.1,60,,44.88,percent of total billed charges,60% of total billed charges,44.88,48,,35.904,percent of total billed charges,48% of total billed charges,24.79,100,,,fee schedule,100% of bcbs custom fee schedule,24.79,100,,,fee schedule,100% of bcbs custom fee schedule,27.52,111,,,fee schedule,111% of bcbs custom fee schedule,46.75,50,,37.4,percent of total billed charges,50% of total billed charges,65.45,70,,52.36,percent of total billed charges,70% of total billed charges,45.33,48.48,,36.264,percent of total billed charges,48.48% of total billed charges,8.27,101,,,fee schedule,101% of cms custom fee schedule,45.33,48.48,,36.264,percent of total billed charges,48.48% of total billed charges,65.45,70,,52.36,percent of total billed charges,70% of total billed charges,65.45,70,,52.36,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,45.33,48.48,,36.264,percent of total billed charges,48.48% of total billed charges,84.15,90,,67.32,percent of total billed charges,90% of total billed charges,45.33,90,
SALICYLATE LEVEL,,,300,RC,80179,HCPCS,outpatient,,,53,31.80,,31.8,60,,25.44,percent of total billed charges,60% of total billed charges,25.44,48,,20.352,percent of total billed charges,48% of total billed charges,26.5,50,,21.2,percent of total billed charges,50% of total billed charges,26.5,50,,21.2,percent of total billed charges,50% of total billed charges,26.5,50,,21.2,percent of total billed charges,50% of total billed charges,26.5,50,,21.2,percent of total billed charges,50% of total billed charges,37.1,70,,29.68,percent of total billed charges,70% of total billed charges,25.69,48.48,,20.552,percent of total billed charges,48.48% of total billed charges,18.83,101,,,fee schedule,101% of cms custom fee schedule,25.69,48.48,,20.552,percent of total billed charges,48.48% of total billed charges,37.1,70,,29.68,percent of total billed charges,70% of total billed charges,37.1,70,,29.68,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,25.69,48.48,,20.552,percent of total billed charges,48.48% of total billed charges,47.7,90,,38.16,percent of total billed charges,90% of total billed charges,25.69,90,
Lysozyme (Muramidase),,,300,RC,85549,HCPCS,outpatient,,,185,111.00,,111,60,,88.8,percent of total billed charges,60% of total billed charges,88.8,48,,71.04,percent of total billed charges,48% of total billed charges,56.81,100,,,fee schedule,100% of bcbs custom fee schedule,56.81,100,,,fee schedule,100% of bcbs custom fee schedule,63.06,111,,,fee schedule,111% of bcbs custom fee schedule,92.5,50,,74,percent of total billed charges,50% of total billed charges,129.5,70,,103.6,percent of total billed charges,70% of total billed charges,89.69,48.48,,71.752,percent of total billed charges,48.48% of total billed charges,18.94,101,,,fee schedule,101% of cms custom fee schedule,89.69,48.48,,71.752,percent of total billed charges,48.48% of total billed charges,129.5,70,,103.6,percent of total billed charges,70% of total billed charges,129.5,70,,103.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,89.69,48.48,,71.752,percent of total billed charges,48.48% of total billed charges,166.5,90,,133.2,percent of total billed charges,90% of total billed charges,48.48,166.5,
PROLACTIN LEVEL,41001020,CDM,301,RC,84146,HCPCS,outpatient,,,134.5,80.70,,80.7,60,,64.56,percent of total billed charges,60% of total billed charges,64.56,48,,51.648,percent of total billed charges,48% of total billed charges,58.71,100,,,fee schedule,100% of bcbs custom fee schedule,58.71,100,,,fee schedule,100% of bcbs custom fee schedule,65.17,111,,,fee schedule,111% of bcbs custom fee schedule,67.25,50,,53.8,percent of total billed charges,50% of total billed charges,94.15,70,,75.32,percent of total billed charges,70% of total billed charges,65.21,48.48,,52.168,percent of total billed charges,48.48% of total billed charges,19.57,101,,,fee schedule,101% of cms custom fee schedule,65.21,48.48,,52.168,percent of total billed charges,48.48% of total billed charges,94.15,70,,75.32,percent of total billed charges,70% of total billed charges,94.15,70,,75.32,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,65.21,48.48,,52.168,percent of total billed charges,48.48% of total billed charges,121.05,90,,96.84,percent of total billed charges,90% of total billed charges,48.48,121.05,
"TROPONIN, QUAN",41000359,CDM,301,RC,84484,HCPCS,outpatient,,,106.5,63.90,,63.9,60,,51.12,percent of total billed charges,60% of total billed charges,51.12,48,,40.896,percent of total billed charges,48% of total billed charges,29.81,100,,,fee schedule,100% of bcbs custom fee schedule,29.81,100,,,fee schedule,100% of bcbs custom fee schedule,33.09,111,,,fee schedule,111% of bcbs custom fee schedule,53.25,50,,42.6,percent of total billed charges,50% of total billed charges,74.55,70,,59.64,percent of total billed charges,70% of total billed charges,51.63,48.48,,41.304,percent of total billed charges,48.48% of total billed charges,12.59,101,,,fee schedule,101% of cms custom fee schedule,51.63,48.48,,41.304,percent of total billed charges,48.48% of total billed charges,74.55,70,,59.64,percent of total billed charges,70% of total billed charges,74.55,70,,59.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,51.63,48.48,,41.304,percent of total billed charges,48.48% of total billed charges,95.85,90,,76.68,percent of total billed charges,90% of total billed charges,48.48,95.85,
IMMUNOGLOBULINS QUANT IGA/IGD/IGG/IGM EA,41000061,CDM,300,RC,82784,HCPCS,outpatient,,,101.25,60.75,,60.75,60,,48.6,percent of total billed charges,60% of total billed charges,48.6,48,,38.88,percent of total billed charges,48% of total billed charges,28.16,100,,,fee schedule,100% of bcbs custom fee schedule,28.16,100,,,fee schedule,100% of bcbs custom fee schedule,31.26,111,,,fee schedule,111% of bcbs custom fee schedule,50.63,50,,40.504,percent of total billed charges,50% of total billed charges,70.88,70,,56.704,percent of total billed charges,70% of total billed charges,49.09,48.48,,39.272,percent of total billed charges,48.48% of total billed charges,9.39,101,,,fee schedule,101% of cms custom fee schedule,49.09,48.48,,39.272,percent of total billed charges,48.48% of total billed charges,70.88,70,,56.704,percent of total billed charges,70% of total billed charges,70.88,70,,56.704,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,49.09,48.48,,39.272,percent of total billed charges,48.48% of total billed charges,91.13,90,,72.904,percent of total billed charges,90% of total billed charges,48.48,91.13,
MANUAL DIFFERENTIAL,41000105,CDM,305,RC,85007,HCPCS,outpatient,,,30,18.00,,18,60,,14.4,percent of total billed charges,60% of total billed charges,14.4,48,,11.52,percent of total billed charges,48% of total billed charges,7.58,100,,,fee schedule,100% of bcbs custom fee schedule,7.58,100,,,fee schedule,100% of bcbs custom fee schedule,8.41,111,,,fee schedule,111% of bcbs custom fee schedule,15,50,,12,percent of total billed charges,50% of total billed charges,21,70,,16.8,percent of total billed charges,70% of total billed charges,14.54,48.48,,11.632,percent of total billed charges,48.48% of total billed charges,3.84,101,,,fee schedule,101% of cms custom fee schedule,14.54,48.48,,11.632,percent of total billed charges,48.48% of total billed charges,21,70,,16.8,percent of total billed charges,70% of total billed charges,21,70,,16.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,14.54,48.48,,11.632,percent of total billed charges,48.48% of total billed charges,27,90,,21.6,percent of total billed charges,90% of total billed charges,14.54,90,
PROCALCITONIN,41001229,CDM,300,RC,84145,HCPCS,outpatient,,,250,150.00,,150,60,,120,percent of total billed charges,60% of total billed charges,120,48,,96,percent of total billed charges,48% of total billed charges,41.79,100,,,fee schedule,100% of bcbs custom fee schedule,41.79,100,,,fee schedule,100% of bcbs custom fee schedule,46.39,111,,,fee schedule,111% of bcbs custom fee schedule,125,50,,100,percent of total billed charges,50% of total billed charges,175,70,,140,percent of total billed charges,70% of total billed charges,121.2,48.48,,96.96,percent of total billed charges,48.48% of total billed charges,27.49,101,,,fee schedule,101% of cms custom fee schedule,121.2,48.48,,96.96,percent of total billed charges,48.48% of total billed charges,175,70,,140,percent of total billed charges,70% of total billed charges,175,70,,140,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,121.2,48.48,,96.96,percent of total billed charges,48.48% of total billed charges,225,90,,180,percent of total billed charges,90% of total billed charges,48.48,225,
Saccharomyces Cerevisiae Antibodies,41001139,CDM,300,RC,86671,HCPCS,outpatient,,,105.6,63.36,91,63.36,60,,50.688,percent of total billed charges,60% of total billed charges,50.69,48,,40.552,percent of total billed charges,48% of total billed charges,37.14,100,,,fee schedule,100% of bcbs custom fee schedule,37.14,100,,,fee schedule,100% of bcbs custom fee schedule,41.23,111,,,fee schedule,111% of bcbs custom fee schedule,52.8,50,,42.24,percent of total billed charges,50% of total billed charges,73.92,70,,59.136,percent of total billed charges,70% of total billed charges,51.19,48.48,,40.952,percent of total billed charges,48.48% of total billed charges,12.37,101,,,fee schedule,101% of cms custom fee schedule,51.19,48.48,,40.952,percent of total billed charges,48.48% of total billed charges,73.92,70,,59.136,percent of total billed charges,70% of total billed charges,73.92,70,,59.136,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,51.19,48.48,,40.952,percent of total billed charges,48.48% of total billed charges,95.04,90,,76.032,percent of total billed charges,90% of total billed charges,48.48,95.04,
ALKALINE PHOSPHATASE ISOENZYMES,41001100,CDM,300,RC,84080,HCPCS,outpatient,,,90.85,54.51,,54.51,60,,43.608,percent of total billed charges,60% of total billed charges,43.61,48,,34.888,percent of total billed charges,48% of total billed charges,44.79,100,,,fee schedule,100% of bcbs custom fee schedule,44.79,100,,,fee schedule,100% of bcbs custom fee schedule,49.72,111,,,fee schedule,111% of bcbs custom fee schedule,45.43,50,,36.344,percent of total billed charges,50% of total billed charges,63.6,70,,50.88,percent of total billed charges,70% of total billed charges,44.04,48.48,,35.232,percent of total billed charges,48.48% of total billed charges,14.93,101,,,fee schedule,101% of cms custom fee schedule,44.04,48.48,,35.232,percent of total billed charges,48.48% of total billed charges,63.6,70,,50.88,percent of total billed charges,70% of total billed charges,63.6,70,,50.88,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,44.04,48.48,,35.232,percent of total billed charges,48.48% of total billed charges,81.77,90,,65.416,percent of total billed charges,90% of total billed charges,44.04,90,
PLATELET COUNT,41000108,CDM,300,RC,85049,HCPCS,outpatient,,,35,21.00,,21,60,,16.8,percent of total billed charges,60% of total billed charges,16.8,48,,13.44,percent of total billed charges,48% of total billed charges,12.43,100,,,fee schedule,100% of bcbs custom fee schedule,12.43,100,,,fee schedule,100% of bcbs custom fee schedule,13.8,111,,,fee schedule,111% of bcbs custom fee schedule,17.5,50,,14,percent of total billed charges,50% of total billed charges,24.5,70,,19.6,percent of total billed charges,70% of total billed charges,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,4.52,101,,,fee schedule,101% of cms custom fee schedule,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,24.5,70,,19.6,percent of total billed charges,70% of total billed charges,24.5,70,,19.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,31.5,90,,25.2,percent of total billed charges,90% of total billed charges,16.97,90,
DIRECT LDL,41000153,CDM,300,RC,83721,HCPCS,outpatient,,,65,39.00,,39,60,,31.2,percent of total billed charges,60% of total billed charges,31.2,48,,24.96,percent of total billed charges,48% of total billed charges,25.88,100,,,fee schedule,100% of bcbs custom fee schedule,25.88,100,,,fee schedule,100% of bcbs custom fee schedule,28.73,111,,,fee schedule,111% of bcbs custom fee schedule,32.5,50,,26,percent of total billed charges,50% of total billed charges,45.5,70,,36.4,percent of total billed charges,70% of total billed charges,31.51,48.48,,25.208,percent of total billed charges,48.48% of total billed charges,10.61,101,,,fee schedule,101% of cms custom fee schedule,31.51,48.48,,25.208,percent of total billed charges,48.48% of total billed charges,45.5,70,,36.4,percent of total billed charges,70% of total billed charges,45.5,70,,36.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,31.51,48.48,,25.208,percent of total billed charges,48.48% of total billed charges,58.5,90,,46.8,percent of total billed charges,90% of total billed charges,31.51,90,
SICKLE CELL PREP,41000111,CDM,300,RC,85660,HCPCS,outpatient,,,62.5,37.50,,37.5,60,,30,percent of total billed charges,60% of total billed charges,30,48,,24,percent of total billed charges,48% of total billed charges,16.71,100,,,fee schedule,100% of bcbs custom fee schedule,16.71,100,,,fee schedule,100% of bcbs custom fee schedule,18.55,111,,,fee schedule,111% of bcbs custom fee schedule,31.25,50,,25,percent of total billed charges,50% of total billed charges,43.75,70,,35,percent of total billed charges,70% of total billed charges,30.3,48.48,,24.24,percent of total billed charges,48.48% of total billed charges,5.57,101,,,fee schedule,101% of cms custom fee schedule,30.3,48.48,,24.24,percent of total billed charges,48.48% of total billed charges,43.75,70,,35,percent of total billed charges,70% of total billed charges,43.75,70,,35,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,30.3,48.48,,24.24,percent of total billed charges,48.48% of total billed charges,56.25,90,,45,percent of total billed charges,90% of total billed charges,30.3,90,
"Metanephrines, Plasma",41000031,CDM,300,RC,83835,HCPCS,outpatient,,,325,195.00,,195,60,,156,percent of total billed charges,60% of total billed charges,156,48,,124.8,percent of total billed charges,48% of total billed charges,51.3,100,,,fee schedule,100% of bcbs custom fee schedule,51.3,100,,,fee schedule,100% of bcbs custom fee schedule,56.94,111,,,fee schedule,111% of bcbs custom fee schedule,162.5,50,,130,percent of total billed charges,50% of total billed charges,227.5,70,,182,percent of total billed charges,70% of total billed charges,157.56,48.48,,126.048,percent of total billed charges,48.48% of total billed charges,17.11,101,,,fee schedule,101% of cms custom fee schedule,157.56,48.48,,126.048,percent of total billed charges,48.48% of total billed charges,227.5,70,,182,percent of total billed charges,70% of total billed charges,227.5,70,,182,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,157.56,48.48,,126.048,percent of total billed charges,48.48% of total billed charges,292.5,90,,234,percent of total billed charges,90% of total billed charges,48.48,292.5,
RH(BLOOD),41040217,CDM,300,RC,86901,HCPCS,outpatient,,,51.25,30.75,,30.75,60,,24.6,percent of total billed charges,60% of total billed charges,24.6,48,,19.68,percent of total billed charges,48% of total billed charges,10.32,100,,,fee schedule,100% of bcbs custom fee schedule,10.32,100,,,fee schedule,100% of bcbs custom fee schedule,11.46,111,,,fee schedule,111% of bcbs custom fee schedule,25.63,50,,20.504,percent of total billed charges,50% of total billed charges,35.88,70,,28.704,percent of total billed charges,70% of total billed charges,24.85,48.48,,19.88,percent of total billed charges,48.48% of total billed charges,3.02,101,,,fee schedule,101% of cms custom fee schedule,24.85,48.48,,19.88,percent of total billed charges,48.48% of total billed charges,35.88,70,,28.704,percent of total billed charges,70% of total billed charges,35.88,70,,28.704,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,24.85,48.48,,19.88,percent of total billed charges,48.48% of total billed charges,46.13,90,,36.904,percent of total billed charges,90% of total billed charges,24.85,90,
MINIMUM INHIBITORY CONCENTRATION,,,300,RC,87186,HCPCS,outpatient,,,93.75,56.25,,56.25,60,,45,percent of total billed charges,60% of total billed charges,45,48,,36,percent of total billed charges,48% of total billed charges,26.19,100,,,fee schedule,100% of bcbs custom fee schedule,26.19,100,,,fee schedule,100% of bcbs custom fee schedule,29.07,111,,,fee schedule,111% of bcbs custom fee schedule,46.88,50,,37.504,percent of total billed charges,50% of total billed charges,65.63,70,,52.504,percent of total billed charges,70% of total billed charges,45.45,48.48,,36.36,percent of total billed charges,48.48% of total billed charges,8.74,101,,,fee schedule,101% of cms custom fee schedule,45.45,48.48,,36.36,percent of total billed charges,48.48% of total billed charges,65.63,70,,52.504,percent of total billed charges,70% of total billed charges,65.63,70,,52.504,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,45.45,48.48,,36.36,percent of total billed charges,48.48% of total billed charges,84.38,90,,67.504,percent of total billed charges,90% of total billed charges,45.45,90,
BLOOD SMEAR (MALERIA),41000199,CDM,300,RC,87207,HCPCS,outpatient,,,67.5,40.50,,40.5,60,,32.4,percent of total billed charges,60% of total billed charges,32.4,48,,25.92,percent of total billed charges,48% of total billed charges,18.15,100,,,fee schedule,100% of bcbs custom fee schedule,18.15,100,,,fee schedule,100% of bcbs custom fee schedule,20.15,111,,,fee schedule,111% of bcbs custom fee schedule,33.75,50,,27,percent of total billed charges,50% of total billed charges,47.25,70,,37.8,percent of total billed charges,70% of total billed charges,32.72,48.48,,26.176,percent of total billed charges,48.48% of total billed charges,6.05,101,,,fee schedule,101% of cms custom fee schedule,32.72,48.48,,26.176,percent of total billed charges,48.48% of total billed charges,47.25,70,,37.8,percent of total billed charges,70% of total billed charges,47.25,70,,37.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,32.72,48.48,,26.176,percent of total billed charges,48.48% of total billed charges,60.75,90,,48.6,percent of total billed charges,90% of total billed charges,32.72,90,
PAP SMEAR,,,311,RC,,,outpatient,,,61.25,36.75,,36.75,60,,29.4,percent of total billed charges,60% of total billed charges,29.4,48,,23.52,percent of total billed charges,48% of total billed charges,30.63,50,,24.504,percent of total billed charges,50% of total billed charges,30.63,50,,24.504,percent of total billed charges,50% of total billed charges,30.63,50,,24.504,percent of total billed charges,50% of total billed charges,30.63,50,,24.504,percent of total billed charges,50% of total billed charges,42.88,70,,34.304,percent of total billed charges,70% of total billed charges,29.69,48.48,,23.752,percent of total billed charges,48.48% of total billed charges,29.69,48.48,,23.752,percent of total billed charges,48.48% of total billed charges,29.69,48.48,,23.752,percent of total billed charges,48.48% of total billed charges,42.88,70,,34.304,percent of total billed charges,70% of total billed charges,42.88,70,,34.304,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,29.69,48.48,,23.752,percent of total billed charges,48.48% of total billed charges,55.13,90,,44.104,percent of total billed charges,90% of total billed charges,29.69,90,
Inhibin A,,,300,RC,86336,HCPCS,outpatient,,,250,150.00,,150,60,,120,percent of total billed charges,60% of total billed charges,120,48,,96,percent of total billed charges,48% of total billed charges,47.2,100,,,fee schedule,100% of bcbs custom fee schedule,47.2,100,,,fee schedule,100% of bcbs custom fee schedule,52.39,111,,,fee schedule,111% of bcbs custom fee schedule,125,50,,100,percent of total billed charges,50% of total billed charges,175,70,,140,percent of total billed charges,70% of total billed charges,121.2,48.48,,96.96,percent of total billed charges,48.48% of total billed charges,15.75,101,,,fee schedule,101% of cms custom fee schedule,121.2,48.48,,96.96,percent of total billed charges,48.48% of total billed charges,175,70,,140,percent of total billed charges,70% of total billed charges,175,70,,140,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,121.2,48.48,,96.96,percent of total billed charges,48.48% of total billed charges,225,90,,180,percent of total billed charges,90% of total billed charges,48.48,225,
GLUCOSE,41000009,CDM,301,RC,82947,HCPCS,outpatient,,,46.25,27.75,,27.75,60,,22.2,percent of total billed charges,60% of total billed charges,22.2,48,,17.76,percent of total billed charges,48% of total billed charges,11.88,100,,,fee schedule,100% of bcbs custom fee schedule,11.88,100,,,fee schedule,100% of bcbs custom fee schedule,13.19,111,,,fee schedule,111% of bcbs custom fee schedule,23.13,50,,18.504,percent of total billed charges,50% of total billed charges,32.38,70,,25.904,percent of total billed charges,70% of total billed charges,22.42,48.48,,17.936,percent of total billed charges,48.48% of total billed charges,3.97,101,,,fee schedule,101% of cms custom fee schedule,22.42,48.48,,17.936,percent of total billed charges,48.48% of total billed charges,32.38,70,,25.904,percent of total billed charges,70% of total billed charges,32.38,70,,25.904,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,22.42,48.48,,17.936,percent of total billed charges,48.48% of total billed charges,41.63,90,,33.304,percent of total billed charges,90% of total billed charges,22.42,90,
BASIC METABOLIC PANEL,41000365,CDM,301,RC,80048,HCPCS,outpatient,,,113.75,68.25,,13,100,,,fee schedule,100% of aetna fee schedule,54.6,48,,43.68,percent of total billed charges,48% of total billed charges,25.65,100,,,fee schedule,100% of bcbs custom fee schedule,25.65,100,,,fee schedule,100% of bcbs custom fee schedule,28.47,111,,,fee schedule,111% of bcbs custom fee schedule,56.88,50,,45.504,percent of total billed charges,50% of total billed charges,79.63,70,,63.704,percent of total billed charges,70% of total billed charges,55.15,48.48,,44.12,percent of total billed charges,48.48% of total billed charges,8.54,101,,,fee schedule,101% of cms custom fee schedule,55.15,48.48,,44.12,percent of total billed charges,48.48% of total billed charges,79.63,70,,63.704,percent of total billed charges,70% of total billed charges,79.63,70,,63.704,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,55.15,48.48,,44.12,percent of total billed charges,48.48% of total billed charges,102.38,90,,81.904,percent of total billed charges,90% of total billed charges,48.48,102.38,
KOH,41000133,CDM,300,RC,87220,HCPCS,outpatient,,,32.5,19.50,,19.5,60,,15.6,percent of total billed charges,60% of total billed charges,15.6,48,,12.48,percent of total billed charges,48% of total billed charges,12.91,100,,,fee schedule,100% of bcbs custom fee schedule,12.91,100,,,fee schedule,100% of bcbs custom fee schedule,14.33,111,,,fee schedule,111% of bcbs custom fee schedule,16.25,50,,13,percent of total billed charges,50% of total billed charges,22.75,70,,18.2,percent of total billed charges,70% of total billed charges,15.76,48.48,,12.608,percent of total billed charges,48.48% of total billed charges,4.31,101,,,fee schedule,101% of cms custom fee schedule,15.76,48.48,,12.608,percent of total billed charges,48.48% of total billed charges,22.75,70,,18.2,percent of total billed charges,70% of total billed charges,22.75,70,,18.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,15.76,48.48,,12.608,percent of total billed charges,48.48% of total billed charges,29.25,90,,23.4,percent of total billed charges,90% of total billed charges,15.76,90,
MTHFR Gene Analysis,,,300,RC,81291,HCPCS,outpatient,,,420,252.00,,252,60,,201.6,percent of total billed charges,60% of total billed charges,201.6,48,,161.28,percent of total billed charges,48% of total billed charges,119.55,100,,,fee schedule,100% of bcbs custom fee schedule,119.55,100,,,fee schedule,100% of bcbs custom fee schedule,132.7,111,,,fee schedule,111% of bcbs custom fee schedule,210,50,,168,percent of total billed charges,50% of total billed charges,294,70,,235.2,percent of total billed charges,70% of total billed charges,203.62,48.48,,162.896,percent of total billed charges,48.48% of total billed charges,65.99,101,,,fee schedule,101% of cms custom fee schedule,203.62,48.48,,162.896,percent of total billed charges,48.48% of total billed charges,294,70,,235.2,percent of total billed charges,70% of total billed charges,294,70,,235.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,203.62,48.48,,162.896,percent of total billed charges,48.48% of total billed charges,378,90,,302.4,percent of total billed charges,90% of total billed charges,48.48,378,
Antibody ID Panel,41040264,CDM,300,RC,86870,HCPCS,outpatient,,,187.5,112.50,91,112.5,60,,90,percent of total billed charges,60% of total billed charges,90,48,,72,percent of total billed charges,48% of total billed charges,35.68,100,,,fee schedule,100% of bcbs custom fee schedule,35.68,100,,,fee schedule,100% of bcbs custom fee schedule,39.6,111,,,fee schedule,111% of bcbs custom fee schedule,93.75,50,,75,percent of total billed charges,50% of total billed charges,131.25,70,,105,percent of total billed charges,70% of total billed charges,90.9,48.48,,72.72,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,90.9,48.48,,72.72,percent of total billed charges,48.48% of total billed charges,131.25,70,,105,percent of total billed charges,70% of total billed charges,131.25,70,,105,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,90.9,48.48,,72.72,percent of total billed charges,48.48% of total billed charges,168.75,90,,135,percent of total billed charges,90% of total billed charges,48.48,168.75,
"Select Cell Screen, each",41040301,CDM,300,RC,86850,HCPCS,outpatient,,,125,75.00,91,75,60,,60,percent of total billed charges,60% of total billed charges,60,48,,48,percent of total billed charges,48% of total billed charges,20.64,100,,,fee schedule,100% of bcbs custom fee schedule,20.64,100,,,fee schedule,100% of bcbs custom fee schedule,22.91,111,,,fee schedule,111% of bcbs custom fee schedule,62.5,50,,50,percent of total billed charges,50% of total billed charges,87.5,70,,70,percent of total billed charges,70% of total billed charges,60.6,48.48,,48.48,percent of total billed charges,48.48% of total billed charges,9.87,101,,,fee schedule,101% of cms custom fee schedule,60.6,48.48,,48.48,percent of total billed charges,48.48% of total billed charges,87.5,70,,70,percent of total billed charges,70% of total billed charges,87.5,70,,70,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,60.6,48.48,,48.48,percent of total billed charges,48.48% of total billed charges,112.5,90,,90,percent of total billed charges,90% of total billed charges,48.48,112.5,
"Antigen screen, each",41040324,CDM,300,RC,86905,HCPCS,outpatient,,,112.5,67.50,91,67.5,60,,54,percent of total billed charges,60% of total billed charges,54,48,,43.2,percent of total billed charges,48% of total billed charges,11.58,100,,,fee schedule,100% of bcbs custom fee schedule,11.58,100,,,fee schedule,100% of bcbs custom fee schedule,12.85,111,,,fee schedule,111% of bcbs custom fee schedule,56.25,50,,45,percent of total billed charges,50% of total billed charges,78.75,70,,63,percent of total billed charges,70% of total billed charges,54.54,48.48,,43.632,percent of total billed charges,48.48% of total billed charges,3.87,101,,,fee schedule,101% of cms custom fee schedule,54.54,48.48,,43.632,percent of total billed charges,48.48% of total billed charges,78.75,70,,63,percent of total billed charges,70% of total billed charges,78.75,70,,63,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,54.54,48.48,,43.632,percent of total billed charges,48.48% of total billed charges,101.25,90,,81,percent of total billed charges,90% of total billed charges,48.48,101.25,
Incubation technique XM each,,,300,RC,86921,HCPCS,outpatient,,,85,51.00,91,51,60,,40.8,percent of total billed charges,60% of total billed charges,40.8,48,,32.64,percent of total billed charges,48% of total billed charges,22.12,100,,,fee schedule,100% of bcbs custom fee schedule,22.12,100,,,fee schedule,100% of bcbs custom fee schedule,24.55,111,,,fee schedule,111% of bcbs custom fee schedule,42.5,50,,34,percent of total billed charges,50% of total billed charges,59.5,70,,47.6,percent of total billed charges,70% of total billed charges,41.21,48.48,,32.968,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,41.21,48.48,,32.968,percent of total billed charges,48.48% of total billed charges,59.5,70,,47.6,percent of total billed charges,70% of total billed charges,59.5,70,,47.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,41.21,48.48,,32.968,percent of total billed charges,48.48% of total billed charges,76.5,90,,61.2,percent of total billed charges,90% of total billed charges,41.21,90,
Coombs Technique XM each,41040203,CDM,300,RC,86922,HCPCS,outpatient,,,85,51.00,91,51,60,,40.8,percent of total billed charges,60% of total billed charges,40.8,48,,32.64,percent of total billed charges,48% of total billed charges,13.46,100,,,fee schedule,100% of bcbs custom fee schedule,13.46,100,,,fee schedule,100% of bcbs custom fee schedule,14.94,111,,,fee schedule,111% of bcbs custom fee schedule,42.5,50,,34,percent of total billed charges,50% of total billed charges,59.5,70,,47.6,percent of total billed charges,70% of total billed charges,41.21,48.48,,32.968,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,41.21,48.48,,32.968,percent of total billed charges,48.48% of total billed charges,59.5,70,,47.6,percent of total billed charges,70% of total billed charges,59.5,70,,47.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,41.21,48.48,,32.968,percent of total billed charges,48.48% of total billed charges,76.5,90,,61.2,percent of total billed charges,90% of total billed charges,41.21,90,
"Elution Prep, each",41040323,CDM,300,RC,86860,HCPCS,outpatient,,,137.5,82.50,91,82.5,60,,66,percent of total billed charges,60% of total billed charges,66,48,,52.8,percent of total billed charges,48% of total billed charges,21.34,100,,,fee schedule,100% of bcbs custom fee schedule,21.34,100,,,fee schedule,100% of bcbs custom fee schedule,23.69,111,,,fee schedule,111% of bcbs custom fee schedule,68.75,50,,55,percent of total billed charges,50% of total billed charges,96.25,70,,77,percent of total billed charges,70% of total billed charges,66.66,48.48,,53.328,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,66.66,48.48,,53.328,percent of total billed charges,48.48% of total billed charges,96.25,70,,77,percent of total billed charges,70% of total billed charges,96.25,70,,77,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,66.66,48.48,,53.328,percent of total billed charges,48.48% of total billed charges,123.75,90,,99,percent of total billed charges,90% of total billed charges,48.48,123.75,
FLUORESCENT ANTIBODY SCREEN,41000204,CDM,300,RC,86255,HCPCS,outpatient,,,275,165.00,,165,60,,132,percent of total billed charges,60% of total billed charges,132,48,,105.6,percent of total billed charges,48% of total billed charges,34.38,100,,,fee schedule,100% of bcbs custom fee schedule,34.38,100,,,fee schedule,100% of bcbs custom fee schedule,38.16,111,,,fee schedule,111% of bcbs custom fee schedule,137.5,50,,110,percent of total billed charges,50% of total billed charges,192.5,70,,154,percent of total billed charges,70% of total billed charges,133.32,48.48,,106.656,percent of total billed charges,48.48% of total billed charges,12.17,101,,,fee schedule,101% of cms custom fee schedule,133.32,48.48,,106.656,percent of total billed charges,48.48% of total billed charges,192.5,70,,154,percent of total billed charges,70% of total billed charges,192.5,70,,154,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,133.32,48.48,,106.656,percent of total billed charges,48.48% of total billed charges,247.5,90,,198,percent of total billed charges,90% of total billed charges,48.48,247.5,
Alpha 1 Antitrypsin Phenotype,,,300,RC,82104,HCPCS,outpatient,,,69,41.40,,41.4,60,,33.12,percent of total billed charges,60% of total billed charges,33.12,48,,26.496,percent of total billed charges,48% of total billed charges,43.8,100,,,fee schedule,100% of bcbs custom fee schedule,43.8,100,,,fee schedule,100% of bcbs custom fee schedule,48.62,111,,,fee schedule,111% of bcbs custom fee schedule,34.5,50,,27.6,percent of total billed charges,50% of total billed charges,48.3,70,,38.64,percent of total billed charges,70% of total billed charges,33.45,48.48,,26.76,percent of total billed charges,48.48% of total billed charges,14.6,101,,,fee schedule,101% of cms custom fee schedule,33.45,48.48,,26.76,percent of total billed charges,48.48% of total billed charges,48.3,70,,38.64,percent of total billed charges,70% of total billed charges,48.3,70,,38.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,33.45,48.48,,26.76,percent of total billed charges,48.48% of total billed charges,62.1,90,,49.68,percent of total billed charges,90% of total billed charges,33.45,90,
ACETONE/KETONE SERUM,41000219,CDM,300,RC,82010,HCPCS,outpatient,,,60,36.00,,36,60,,28.8,percent of total billed charges,60% of total billed charges,28.8,48,,23.04,percent of total billed charges,48% of total billed charges,24.75,100,,,fee schedule,100% of bcbs custom fee schedule,24.75,100,,,fee schedule,100% of bcbs custom fee schedule,27.47,111,,,fee schedule,111% of bcbs custom fee schedule,30,50,,24,percent of total billed charges,50% of total billed charges,42,70,,33.6,percent of total billed charges,70% of total billed charges,29.09,48.48,,23.272,percent of total billed charges,48.48% of total billed charges,8.25,101,,,fee schedule,101% of cms custom fee schedule,29.09,48.48,,23.272,percent of total billed charges,48.48% of total billed charges,42,70,,33.6,percent of total billed charges,70% of total billed charges,42,70,,33.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,29.09,48.48,,23.272,percent of total billed charges,48.48% of total billed charges,54,90,,43.2,percent of total billed charges,90% of total billed charges,29.09,90,
ACTH,41000200,CDM,300,RC,82024,HCPCS,outpatient,,,269.5,161.70,,161.7,60,,129.36,percent of total billed charges,60% of total billed charges,129.36,48,,103.488,percent of total billed charges,48% of total billed charges,117,100,,,fee schedule,100% of bcbs custom fee schedule,117,100,,,fee schedule,100% of bcbs custom fee schedule,129.87,111,,,fee schedule,111% of bcbs custom fee schedule,134.75,50,,107.8,percent of total billed charges,50% of total billed charges,188.65,70,,150.92,percent of total billed charges,70% of total billed charges,130.65,48.48,,104.52,percent of total billed charges,48.48% of total billed charges,39.01,101,,,fee schedule,101% of cms custom fee schedule,130.65,48.48,,104.52,percent of total billed charges,48.48% of total billed charges,188.65,70,,150.92,percent of total billed charges,70% of total billed charges,188.65,70,,150.92,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,130.65,48.48,,104.52,percent of total billed charges,48.48% of total billed charges,242.55,90,,194.04,percent of total billed charges,90% of total billed charges,48.48,242.55,
ALCOHOL LEVEL BLOOD,,,300,RC,82077,HCPCS,outpatient,,,83.75,50.25,,50.25,60,,40.2,percent of total billed charges,60% of total billed charges,40.2,48,,32.16,percent of total billed charges,48% of total billed charges,41.88,50,,33.504,percent of total billed charges,50% of total billed charges,41.88,50,,33.504,percent of total billed charges,50% of total billed charges,41.88,50,,33.504,percent of total billed charges,50% of total billed charges,41.88,50,,33.504,percent of total billed charges,50% of total billed charges,58.63,70,,46.904,percent of total billed charges,70% of total billed charges,40.6,48.48,,32.48,percent of total billed charges,48.48% of total billed charges,17.44,101,,,fee schedule,101% of cms custom fee schedule,40.6,48.48,,32.48,percent of total billed charges,48.48% of total billed charges,58.63,70,,46.904,percent of total billed charges,70% of total billed charges,58.63,70,,46.904,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,40.6,48.48,,32.48,percent of total billed charges,48.48% of total billed charges,75.38,90,,60.304,percent of total billed charges,90% of total billed charges,40.6,90,
AMMONIA,41000062,CDM,300,RC,82140,HCPCS,outpatient,,,123,73.80,,73.8,60,,59.04,percent of total billed charges,60% of total billed charges,59.04,48,,47.232,percent of total billed charges,48% of total billed charges,44.14,100,,,fee schedule,100% of bcbs custom fee schedule,44.14,100,,,fee schedule,100% of bcbs custom fee schedule,49,111,,,fee schedule,111% of bcbs custom fee schedule,61.5,50,,49.2,percent of total billed charges,50% of total billed charges,86.1,70,,68.88,percent of total billed charges,70% of total billed charges,59.63,48.48,,47.704,percent of total billed charges,48.48% of total billed charges,14.72,101,,,fee schedule,101% of cms custom fee schedule,59.63,48.48,,47.704,percent of total billed charges,48.48% of total billed charges,86.1,70,,68.88,percent of total billed charges,70% of total billed charges,86.1,70,,68.88,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,59.63,48.48,,47.704,percent of total billed charges,48.48% of total billed charges,110.7,90,,88.56,percent of total billed charges,90% of total billed charges,48.48,110.7,
PROTEIN C ANTIGEN,41000173,CDM,300,RC,85302,HCPCS,outpatient,,,160,96.00,,96,60,,76.8,percent of total billed charges,60% of total billed charges,76.8,48,,61.44,percent of total billed charges,48% of total billed charges,36.42,100,,,fee schedule,100% of bcbs custom fee schedule,36.42,100,,,fee schedule,100% of bcbs custom fee schedule,40.43,111,,,fee schedule,111% of bcbs custom fee schedule,80,50,,64,percent of total billed charges,50% of total billed charges,112,70,,89.6,percent of total billed charges,70% of total billed charges,77.57,48.48,,62.056,percent of total billed charges,48.48% of total billed charges,12.13,101,,,fee schedule,101% of cms custom fee schedule,77.57,48.48,,62.056,percent of total billed charges,48.48% of total billed charges,112,70,,89.6,percent of total billed charges,70% of total billed charges,112,70,,89.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,77.57,48.48,,62.056,percent of total billed charges,48.48% of total billed charges,144,90,,115.2,percent of total billed charges,90% of total billed charges,48.48,144,
ANA TITER,41000225,CDM,302,RC,86039,HCPCS,outpatient,,,71,42.60,,42.6,60,,34.08,percent of total billed charges,60% of total billed charges,34.08,48,,27.264,percent of total billed charges,48% of total billed charges,33.81,100,,,fee schedule,100% of bcbs custom fee schedule,33.81,100,,,fee schedule,100% of bcbs custom fee schedule,37.53,111,,,fee schedule,111% of bcbs custom fee schedule,35.5,50,,28.4,percent of total billed charges,50% of total billed charges,49.7,70,,39.76,percent of total billed charges,70% of total billed charges,34.42,48.48,,27.536,percent of total billed charges,48.48% of total billed charges,11.27,101,,,fee schedule,101% of cms custom fee schedule,34.42,48.48,,27.536,percent of total billed charges,48.48% of total billed charges,49.7,70,,39.76,percent of total billed charges,70% of total billed charges,49.7,70,,39.76,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,34.42,48.48,,27.536,percent of total billed charges,48.48% of total billed charges,63.9,90,,51.12,percent of total billed charges,90% of total billed charges,34.42,90,
ANTINUCLEAR ANTIBODIES,41000714,CDM,302,RC,86038,HCPCS,outpatient,,,117.5,70.50,,70.5,60,,56.4,percent of total billed charges,60% of total billed charges,56.4,48,,45.12,percent of total billed charges,48% of total billed charges,36.62,100,,,fee schedule,100% of bcbs custom fee schedule,36.62,100,,,fee schedule,100% of bcbs custom fee schedule,40.65,111,,,fee schedule,111% of bcbs custom fee schedule,58.75,50,,47,percent of total billed charges,50% of total billed charges,82.25,70,,65.8,percent of total billed charges,70% of total billed charges,56.96,48.48,,45.568,percent of total billed charges,48.48% of total billed charges,12.21,101,,,fee schedule,101% of cms custom fee schedule,56.96,48.48,,45.568,percent of total billed charges,48.48% of total billed charges,82.25,70,,65.8,percent of total billed charges,70% of total billed charges,82.25,70,,65.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,56.96,48.48,,45.568,percent of total billed charges,48.48% of total billed charges,105.75,90,,84.6,percent of total billed charges,90% of total billed charges,48.48,105.75,
Protein C Activity,41000377,CDM,300,RC,85303,HCPCS,outpatient,,,173.75,104.25,,104.25,60,,83.4,percent of total billed charges,60% of total billed charges,83.4,48,,66.72,percent of total billed charges,48% of total billed charges,38.63,100,,,fee schedule,100% of bcbs custom fee schedule,38.63,100,,,fee schedule,100% of bcbs custom fee schedule,42.88,111,,,fee schedule,111% of bcbs custom fee schedule,86.88,50,,69.504,percent of total billed charges,50% of total billed charges,121.63,70,,97.304,percent of total billed charges,70% of total billed charges,84.23,48.48,,67.384,percent of total billed charges,48.48% of total billed charges,13.98,101,,,fee schedule,101% of cms custom fee schedule,84.23,48.48,,67.384,percent of total billed charges,48.48% of total billed charges,121.63,70,,97.304,percent of total billed charges,70% of total billed charges,121.63,70,,97.304,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,84.23,48.48,,67.384,percent of total billed charges,48.48% of total billed charges,156.38,90,,125.104,percent of total billed charges,90% of total billed charges,48.48,156.38,
"CARDIOLIPIN ANTIBODY, EACH",41000177,CDM,300,RC,86147,HCPCS,outpatient,,,169.5,101.70,,101.7,60,,81.36,percent of total billed charges,60% of total billed charges,81.36,48,,65.088,percent of total billed charges,48% of total billed charges,35.21,100,,,fee schedule,100% of bcbs custom fee schedule,35.21,100,,,fee schedule,100% of bcbs custom fee schedule,39.08,111,,,fee schedule,111% of bcbs custom fee schedule,84.75,50,,67.8,percent of total billed charges,50% of total billed charges,118.65,70,,94.92,percent of total billed charges,70% of total billed charges,82.17,48.48,,65.736,percent of total billed charges,48.48% of total billed charges,25.7,101,,,fee schedule,101% of cms custom fee schedule,82.17,48.48,,65.736,percent of total billed charges,48.48% of total billed charges,118.65,70,,94.92,percent of total billed charges,70% of total billed charges,118.65,70,,94.92,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,82.17,48.48,,65.736,percent of total billed charges,48.48% of total billed charges,152.55,90,,122.04,percent of total billed charges,90% of total billed charges,48.48,152.55,
"Protein S Antigen, Free",41000374,CDM,300,RC,85306,HCPCS,outpatient,,,183.75,110.25,,110.25,60,,88.2,percent of total billed charges,60% of total billed charges,88.2,48,,70.56,percent of total billed charges,48% of total billed charges,46.41,100,,,fee schedule,100% of bcbs custom fee schedule,46.41,100,,,fee schedule,100% of bcbs custom fee schedule,51.52,111,,,fee schedule,111% of bcbs custom fee schedule,91.88,50,,73.504,percent of total billed charges,50% of total billed charges,128.63,70,,102.904,percent of total billed charges,70% of total billed charges,89.08,48.48,,71.264,percent of total billed charges,48.48% of total billed charges,15.47,101,,,fee schedule,101% of cms custom fee schedule,89.08,48.48,,71.264,percent of total billed charges,48.48% of total billed charges,128.63,70,,102.904,percent of total billed charges,70% of total billed charges,128.63,70,,102.904,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,89.08,48.48,,71.264,percent of total billed charges,48.48% of total billed charges,165.38,90,,132.304,percent of total billed charges,90% of total billed charges,48.48,165.38,
Prothrombin (Factor II) 20210G Mutation,,,300,RC,81240,HCPCS,outpatient,,,401.5,240.90,,240.9,60,,192.72,percent of total billed charges,60% of total billed charges,192.72,48,,154.176,percent of total billed charges,48% of total billed charges,120.19,100,,,fee schedule,100% of bcbs custom fee schedule,120.19,100,,,fee schedule,100% of bcbs custom fee schedule,133.41,111,,,fee schedule,111% of bcbs custom fee schedule,200.75,50,,160.6,percent of total billed charges,50% of total billed charges,281.05,70,,224.84,percent of total billed charges,70% of total billed charges,194.65,48.48,,155.72,percent of total billed charges,48.48% of total billed charges,66.35,101,,,fee schedule,101% of cms custom fee schedule,194.65,48.48,,155.72,percent of total billed charges,48.48% of total billed charges,281.05,70,,224.84,percent of total billed charges,70% of total billed charges,281.05,70,,224.84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,194.65,48.48,,155.72,percent of total billed charges,48.48% of total billed charges,361.35,90,,289.08,percent of total billed charges,90% of total billed charges,48.48,361.35,
Antithrombin III Activity,41000386,CDM,300,RC,85300,HCPCS,outpatient,,,178.75,107.25,,107.25,60,,85.8,percent of total billed charges,60% of total billed charges,85.8,48,,68.64,percent of total billed charges,48% of total billed charges,35.87,100,,,fee schedule,100% of bcbs custom fee schedule,35.87,100,,,fee schedule,100% of bcbs custom fee schedule,39.82,111,,,fee schedule,111% of bcbs custom fee schedule,89.38,50,,71.504,percent of total billed charges,50% of total billed charges,125.13,70,,100.104,percent of total billed charges,70% of total billed charges,86.66,48.48,,69.328,percent of total billed charges,48.48% of total billed charges,11.97,101,,,fee schedule,101% of cms custom fee schedule,86.66,48.48,,69.328,percent of total billed charges,48.48% of total billed charges,125.13,70,,100.104,percent of total billed charges,70% of total billed charges,125.13,70,,100.104,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,86.66,48.48,,69.328,percent of total billed charges,48.48% of total billed charges,160.88,90,,128.704,percent of total billed charges,90% of total billed charges,48.48,160.88,
VITAMIN K,,,300,RC,84597,HCPCS,outpatient,,,303.71,182.23,,182.23,60,,145.784,percent of total billed charges,60% of total billed charges,145.78,48,,116.624,percent of total billed charges,48% of total billed charges,41.51,100,,,fee schedule,100% of bcbs custom fee schedule,41.51,100,,,fee schedule,100% of bcbs custom fee schedule,46.08,111,,,fee schedule,111% of bcbs custom fee schedule,151.86,50,,121.488,percent of total billed charges,50% of total billed charges,212.6,70,,170.08,percent of total billed charges,70% of total billed charges,147.24,48.48,,117.792,percent of total billed charges,48.48% of total billed charges,13.86,101,,,fee schedule,101% of cms custom fee schedule,147.24,48.48,,117.792,percent of total billed charges,48.48% of total billed charges,212.6,70,,170.08,percent of total billed charges,70% of total billed charges,212.6,70,,170.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,147.24,48.48,,117.792,percent of total billed charges,48.48% of total billed charges,273.34,90,,218.672,percent of total billed charges,90% of total billed charges,48.48,273.34,
PHOSPHOLIPID ANTIBODY,41000478,CDM,300,RC,83516,HCPCS,outpatient,,,132,79.20,91,79.2,60,,63.36,percent of total billed charges,60% of total billed charges,63.36,48,,50.688,percent of total billed charges,48% of total billed charges,34.94,100,,,fee schedule,100% of bcbs custom fee schedule,34.94,100,,,fee schedule,100% of bcbs custom fee schedule,38.78,111,,,fee schedule,111% of bcbs custom fee schedule,66,50,,52.8,percent of total billed charges,50% of total billed charges,92.4,70,,73.92,percent of total billed charges,70% of total billed charges,63.99,48.48,,51.192,percent of total billed charges,48.48% of total billed charges,11.65,101,,,fee schedule,101% of cms custom fee schedule,63.99,48.48,,51.192,percent of total billed charges,48.48% of total billed charges,92.4,70,,73.92,percent of total billed charges,70% of total billed charges,92.4,70,,73.92,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,63.99,48.48,,51.192,percent of total billed charges,48.48% of total billed charges,118.8,90,,95.04,percent of total billed charges,90% of total billed charges,48.48,118.8,
ASSAY OF ESTRIOL,,,300,RC,82677,HCPCS,outpatient,,,151.5,90.90,,90.9,60,,72.72,percent of total billed charges,60% of total billed charges,72.72,48,,58.176,percent of total billed charges,48% of total billed charges,73.26,100,,,fee schedule,100% of bcbs custom fee schedule,73.26,100,,,fee schedule,100% of bcbs custom fee schedule,81.32,111,,,fee schedule,111% of bcbs custom fee schedule,75.75,50,,60.6,percent of total billed charges,50% of total billed charges,106.05,70,,84.84,percent of total billed charges,70% of total billed charges,73.45,48.48,,58.76,percent of total billed charges,48.48% of total billed charges,24.42,101,,,fee schedule,101% of cms custom fee schedule,73.45,48.48,,58.76,percent of total billed charges,48.48% of total billed charges,106.05,70,,84.84,percent of total billed charges,70% of total billed charges,106.05,70,,84.84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,73.45,48.48,,58.76,percent of total billed charges,48.48% of total billed charges,136.35,90,,109.08,percent of total billed charges,90% of total billed charges,48.48,136.35,
"Nicotine, assay",,,300,RC,G0480,HCPCS,outpatient,,,114.65,68.79,,68.79,60,,55.032,percent of total billed charges,60% of total billed charges,55.03,48,,44.024,percent of total billed charges,48% of total billed charges,146.27,100,,,fee schedule,100% of bcbs custom fee schedule,146.27,100,,,fee schedule,100% of bcbs custom fee schedule,162.36,111,,,fee schedule,111% of bcbs custom fee schedule,57.33,50,,45.864,percent of total billed charges,50% of total billed charges,80.26,70,,64.208,percent of total billed charges,70% of total billed charges,55.58,48.48,,44.464,percent of total billed charges,48.48% of total billed charges,115.57,101,,,fee schedule,101% of cms custom fee schedule,55.58,48.48,,44.464,percent of total billed charges,48.48% of total billed charges,80.26,70,,64.208,percent of total billed charges,70% of total billed charges,80.26,70,,64.208,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,55.58,48.48,,44.464,percent of total billed charges,48.48% of total billed charges,103.19,90,,82.552,percent of total billed charges,90% of total billed charges,48.48,103.19,
VITAMIN A / RETINOL,41001142,CDM,300,RC,84590,HCPCS,outpatient,,,210,126.00,,126,60,,100.8,percent of total billed charges,60% of total billed charges,100.8,48,,80.64,percent of total billed charges,48% of total billed charges,35.12,100,,,fee schedule,100% of bcbs custom fee schedule,35.12,100,,,fee schedule,100% of bcbs custom fee schedule,38.98,111,,,fee schedule,111% of bcbs custom fee schedule,105,50,,84,percent of total billed charges,50% of total billed charges,147,70,,117.6,percent of total billed charges,70% of total billed charges,101.81,48.48,,81.448,percent of total billed charges,48.48% of total billed charges,11.73,101,,,fee schedule,101% of cms custom fee schedule,101.81,48.48,,81.448,percent of total billed charges,48.48% of total billed charges,147,70,,117.6,percent of total billed charges,70% of total billed charges,147,70,,117.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,101.81,48.48,,81.448,percent of total billed charges,48.48% of total billed charges,189,90,,151.2,percent of total billed charges,90% of total billed charges,48.48,189,
INFLUENZA B,43600313,CDM,302,RC,87804,HCPCS,outpatient,,,58.5,35.10,QW,35.1,60,,28.08,percent of total billed charges,60% of total billed charges,28.08,48,,22.464,percent of total billed charges,48% of total billed charges,36.33,100,,,fee schedule,100% of bcbs custom fee schedule,36.33,100,,,fee schedule,100% of bcbs custom fee schedule,40.33,111,,,fee schedule,111% of bcbs custom fee schedule,29.25,50,,23.4,percent of total billed charges,50% of total billed charges,40.95,70,,32.76,percent of total billed charges,70% of total billed charges,28.36,48.48,,22.688,percent of total billed charges,48.48% of total billed charges,16.72,101,,,fee schedule,101% of cms custom fee schedule,28.36,48.48,,22.688,percent of total billed charges,48.48% of total billed charges,40.95,70,,32.76,percent of total billed charges,70% of total billed charges,40.95,70,,32.76,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,28.36,48.48,,22.688,percent of total billed charges,48.48% of total billed charges,52.65,90,,42.12,percent of total billed charges,90% of total billed charges,28.36,90,
Assay of Volatiles,41000342,CDM,300,RC,84600,HCPCS,outpatient,,,225,135.00,,135,60,,108,percent of total billed charges,60% of total billed charges,108,48,,86.4,percent of total billed charges,48% of total billed charges,48.67,100,,,fee schedule,100% of bcbs custom fee schedule,48.67,100,,,fee schedule,100% of bcbs custom fee schedule,54.02,111,,,fee schedule,111% of bcbs custom fee schedule,112.5,50,,90,percent of total billed charges,50% of total billed charges,157.5,70,,126,percent of total billed charges,70% of total billed charges,109.08,48.48,,87.264,percent of total billed charges,48.48% of total billed charges,17.28,101,,,fee schedule,101% of cms custom fee schedule,109.08,48.48,,87.264,percent of total billed charges,48.48% of total billed charges,157.5,70,,126,percent of total billed charges,70% of total billed charges,157.5,70,,126,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,109.08,48.48,,87.264,percent of total billed charges,48.48% of total billed charges,202.5,90,,162,percent of total billed charges,90% of total billed charges,48.48,202.5,
ASSAY URINE SODIUM,41000147,CDM,300,RC,84300,HCPCS,outpatient,,,74,44.40,,44.4,60,,35.52,percent of total billed charges,60% of total billed charges,35.52,48,,28.416,percent of total billed charges,48% of total billed charges,14.72,100,,,fee schedule,100% of bcbs custom fee schedule,14.72,100,,,fee schedule,100% of bcbs custom fee schedule,16.34,111,,,fee schedule,111% of bcbs custom fee schedule,37,50,,29.6,percent of total billed charges,50% of total billed charges,51.8,70,,41.44,percent of total billed charges,70% of total billed charges,35.88,48.48,,28.704,percent of total billed charges,48.48% of total billed charges,5.11,101,,,fee schedule,101% of cms custom fee schedule,35.88,48.48,,28.704,percent of total billed charges,48.48% of total billed charges,51.8,70,,41.44,percent of total billed charges,70% of total billed charges,51.8,70,,41.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,35.88,48.48,,28.704,percent of total billed charges,48.48% of total billed charges,66.6,90,,53.28,percent of total billed charges,90% of total billed charges,35.88,90,
ASSAY OF URINE POTASSIUM,41000143,CDM,300,RC,84133,HCPCS,outpatient,,,70.5,42.30,,42.3,60,,33.84,percent of total billed charges,60% of total billed charges,33.84,48,,27.072,percent of total billed charges,48% of total billed charges,13.03,100,,,fee schedule,100% of bcbs custom fee schedule,13.03,100,,,fee schedule,100% of bcbs custom fee schedule,14.46,111,,,fee schedule,111% of bcbs custom fee schedule,35.25,50,,28.2,percent of total billed charges,50% of total billed charges,49.35,70,,39.48,percent of total billed charges,70% of total billed charges,34.18,48.48,,27.344,percent of total billed charges,48.48% of total billed charges,4.78,101,,,fee schedule,101% of cms custom fee schedule,34.18,48.48,,27.344,percent of total billed charges,48.48% of total billed charges,49.35,70,,39.48,percent of total billed charges,70% of total billed charges,49.35,70,,39.48,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,34.18,48.48,,27.344,percent of total billed charges,48.48% of total billed charges,63.45,90,,50.76,percent of total billed charges,90% of total billed charges,34.18,90,
"URIC ACID, OTHER SOURCE",41009057,CDM,300,RC,84560,HCPCS,outpatient,,,125,75.00,,75,60,,60,percent of total billed charges,60% of total billed charges,60,48,,48,percent of total billed charges,48% of total billed charges,14.39,100,,,fee schedule,100% of bcbs custom fee schedule,14.39,100,,,fee schedule,100% of bcbs custom fee schedule,15.97,111,,,fee schedule,111% of bcbs custom fee schedule,62.5,50,,50,percent of total billed charges,50% of total billed charges,87.5,70,,70,percent of total billed charges,70% of total billed charges,60.6,48.48,,48.48,percent of total billed charges,48.48% of total billed charges,5.13,101,,,fee schedule,101% of cms custom fee schedule,60.6,48.48,,48.48,percent of total billed charges,48.48% of total billed charges,87.5,70,,70,percent of total billed charges,70% of total billed charges,87.5,70,,70,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,60.6,48.48,,48.48,percent of total billed charges,48.48% of total billed charges,112.5,90,,90,percent of total billed charges,90% of total billed charges,48.48,112.5,
HGB-A1C,41000453,CDM,300,RC,83036,HCPCS,outpatient,,,108.75,65.25,,65.25,60,,52.2,percent of total billed charges,60% of total billed charges,52.2,48,,41.76,percent of total billed charges,48% of total billed charges,29.4,100,,,fee schedule,100% of bcbs custom fee schedule,29.4,100,,,fee schedule,100% of bcbs custom fee schedule,32.63,111,,,fee schedule,111% of bcbs custom fee schedule,54.38,50,,43.504,percent of total billed charges,50% of total billed charges,76.13,70,,60.904,percent of total billed charges,70% of total billed charges,52.72,48.48,,42.176,percent of total billed charges,48.48% of total billed charges,9.81,101,,,fee schedule,101% of cms custom fee schedule,52.72,48.48,,42.176,percent of total billed charges,48.48% of total billed charges,76.13,70,,60.904,percent of total billed charges,70% of total billed charges,76.13,70,,60.904,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,52.72,48.48,,42.176,percent of total billed charges,48.48% of total billed charges,97.88,90,,78.304,percent of total billed charges,90% of total billed charges,48.48,97.88,
CULTURE URINE BACT;QUAN,41000506,CDM,300,RC,87086,HCPCS,outpatient,,,75,45.00,,45,60,,36,percent of total billed charges,60% of total billed charges,36,48,,28.8,percent of total billed charges,48% of total billed charges,24.45,100,,,fee schedule,100% of bcbs custom fee schedule,24.45,100,,,fee schedule,100% of bcbs custom fee schedule,27.14,111,,,fee schedule,111% of bcbs custom fee schedule,37.5,50,,30,percent of total billed charges,50% of total billed charges,52.5,70,,42,percent of total billed charges,70% of total billed charges,36.36,48.48,,29.088,percent of total billed charges,48.48% of total billed charges,8.15,101,,,fee schedule,101% of cms custom fee schedule,36.36,48.48,,29.088,percent of total billed charges,48.48% of total billed charges,52.5,70,,42,percent of total billed charges,70% of total billed charges,52.5,70,,42,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,36.36,48.48,,29.088,percent of total billed charges,48.48% of total billed charges,67.5,90,,54,percent of total billed charges,90% of total billed charges,36.36,90,
VALPORIC ACID QUANT,41001241,CDM,300,RC,80164,HCPCS,outpatient,,,105.5,63.30,,63.3,60,,50.64,percent of total billed charges,60% of total billed charges,50.64,48,,40.512,percent of total billed charges,48% of total billed charges,41.04,100,,,fee schedule,100% of bcbs custom fee schedule,41.04,100,,,fee schedule,100% of bcbs custom fee schedule,45.55,111,,,fee schedule,111% of bcbs custom fee schedule,52.75,50,,42.2,percent of total billed charges,50% of total billed charges,73.85,70,,59.08,percent of total billed charges,70% of total billed charges,51.15,48.48,,40.92,percent of total billed charges,48.48% of total billed charges,13.68,101,,,fee schedule,101% of cms custom fee schedule,51.15,48.48,,40.92,percent of total billed charges,48.48% of total billed charges,73.85,70,,59.08,percent of total billed charges,70% of total billed charges,73.85,70,,59.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,51.15,48.48,,40.92,percent of total billed charges,48.48% of total billed charges,94.95,90,,75.96,percent of total billed charges,90% of total billed charges,48.48,94.95,
LITHUIM LEVEL,41009036,CDM,301,RC,80178,HCPCS,outpatient,,,46.25,27.75,,11,100,,,fee schedule,100% of aetna fee schedule,22.2,48,,17.76,percent of total billed charges,48% of total billed charges,20.03,100,,,fee schedule,100% of bcbs custom fee schedule,20.03,100,,,fee schedule,100% of bcbs custom fee schedule,22.23,111,,,fee schedule,111% of bcbs custom fee schedule,23.13,50,,18.504,percent of total billed charges,50% of total billed charges,32.38,70,,25.904,percent of total billed charges,70% of total billed charges,22.42,48.48,,17.936,percent of total billed charges,48.48% of total billed charges,6.68,101,,,fee schedule,101% of cms custom fee schedule,22.42,48.48,,17.936,percent of total billed charges,48.48% of total billed charges,32.38,70,,25.904,percent of total billed charges,70% of total billed charges,32.38,70,,25.904,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,22.42,48.48,,17.936,percent of total billed charges,48.48% of total billed charges,41.63,90,,33.304,percent of total billed charges,90% of total billed charges,22.42,90,
LYME DISEASE ANTIBODY,,,300,RC,86617,HCPCS,outpatient,,,110,66.00,91,66,60,,52.8,percent of total billed charges,60% of total billed charges,52.8,48,,42.24,percent of total billed charges,48% of total billed charges,46.91,100,,,fee schedule,100% of bcbs custom fee schedule,46.91,100,,,fee schedule,100% of bcbs custom fee schedule,52.07,111,,,fee schedule,111% of bcbs custom fee schedule,55,50,,44,percent of total billed charges,50% of total billed charges,77,70,,61.6,percent of total billed charges,70% of total billed charges,53.33,48.48,,42.664,percent of total billed charges,48.48% of total billed charges,15.64,101,,,fee schedule,101% of cms custom fee schedule,53.33,48.48,,42.664,percent of total billed charges,48.48% of total billed charges,77,70,,61.6,percent of total billed charges,70% of total billed charges,77,70,,61.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,53.33,48.48,,42.664,percent of total billed charges,48.48% of total billed charges,99,90,,79.2,percent of total billed charges,90% of total billed charges,48.48,99,
LYME DISEASE ANTIBODY SCREEN,41000012,CDM,300,RC,86618,HCPCS,outpatient,,,146,87.60,,87.6,60,,70.08,percent of total billed charges,60% of total billed charges,70.08,48,,56.064,percent of total billed charges,48% of total billed charges,51.59,100,,,fee schedule,100% of bcbs custom fee schedule,51.59,100,,,fee schedule,100% of bcbs custom fee schedule,57.26,111,,,fee schedule,111% of bcbs custom fee schedule,73,50,,58.4,percent of total billed charges,50% of total billed charges,102.2,70,,81.76,percent of total billed charges,70% of total billed charges,70.78,48.48,,56.624,percent of total billed charges,48.48% of total billed charges,17.2,101,,,fee schedule,101% of cms custom fee schedule,70.78,48.48,,56.624,percent of total billed charges,48.48% of total billed charges,102.2,70,,81.76,percent of total billed charges,70% of total billed charges,102.2,70,,81.76,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,70.78,48.48,,56.624,percent of total billed charges,48.48% of total billed charges,131.4,90,,105.12,percent of total billed charges,90% of total billed charges,48.48,131.4,
BRUCELLA ANTIBODY,,,300,RC,86622,HCPCS,outpatient,,,75,45.00,91,45,60,,36,percent of total billed charges,60% of total billed charges,36,48,,28.8,percent of total billed charges,48% of total billed charges,27.05,100,,,fee schedule,100% of bcbs custom fee schedule,27.05,100,,,fee schedule,100% of bcbs custom fee schedule,30.03,111,,,fee schedule,111% of bcbs custom fee schedule,37.5,50,,30,percent of total billed charges,50% of total billed charges,52.5,70,,42,percent of total billed charges,70% of total billed charges,36.36,48.48,,29.088,percent of total billed charges,48.48% of total billed charges,9.02,101,,,fee schedule,101% of cms custom fee schedule,36.36,48.48,,29.088,percent of total billed charges,48.48% of total billed charges,52.5,70,,42,percent of total billed charges,70% of total billed charges,52.5,70,,42,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,36.36,48.48,,29.088,percent of total billed charges,48.48% of total billed charges,67.5,90,,54,percent of total billed charges,90% of total billed charges,36.36,90,
RICKETTSIA ANTIBODY,,,300,RC,86757,HCPCS,outpatient,,,136.5,81.90,91,81.9,60,,65.52,percent of total billed charges,60% of total billed charges,65.52,48,,52.416,percent of total billed charges,48% of total billed charges,58.64,100,,,fee schedule,100% of bcbs custom fee schedule,58.64,100,,,fee schedule,100% of bcbs custom fee schedule,65.09,111,,,fee schedule,111% of bcbs custom fee schedule,68.25,50,,54.6,percent of total billed charges,50% of total billed charges,95.55,70,,76.44,percent of total billed charges,70% of total billed charges,66.18,48.48,,52.944,percent of total billed charges,48.48% of total billed charges,19.54,101,,,fee schedule,101% of cms custom fee schedule,66.18,48.48,,52.944,percent of total billed charges,48.48% of total billed charges,95.55,70,,76.44,percent of total billed charges,70% of total billed charges,95.55,70,,76.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,66.18,48.48,,52.944,percent of total billed charges,48.48% of total billed charges,122.85,90,,98.28,percent of total billed charges,90% of total billed charges,48.48,122.85,
SALMONELLA ANTIBODY,,,300,RC,86768,HCPCS,outpatient,,,90.5,54.30,91,54.3,60,,43.44,percent of total billed charges,60% of total billed charges,43.44,48,,34.752,percent of total billed charges,48% of total billed charges,39.95,100,,,fee schedule,100% of bcbs custom fee schedule,39.95,100,,,fee schedule,100% of bcbs custom fee schedule,44.34,111,,,fee schedule,111% of bcbs custom fee schedule,45.25,50,,36.2,percent of total billed charges,50% of total billed charges,63.35,70,,50.68,percent of total billed charges,70% of total billed charges,43.87,48.48,,35.096,percent of total billed charges,48.48% of total billed charges,13.32,101,,,fee schedule,101% of cms custom fee schedule,43.87,48.48,,35.096,percent of total billed charges,48.48% of total billed charges,63.35,70,,50.68,percent of total billed charges,70% of total billed charges,63.35,70,,50.68,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,43.87,48.48,,35.096,percent of total billed charges,48.48% of total billed charges,81.45,90,,65.16,percent of total billed charges,90% of total billed charges,43.87,90,
SIROLIMUS LEVEL,41001210,CDM,300,RC,80195,HCPCS,outpatient,,,183,109.80,,109.8,60,,87.84,percent of total billed charges,60% of total billed charges,87.84,48,,70.272,percent of total billed charges,48% of total billed charges,35.08,100,,,fee schedule,100% of bcbs custom fee schedule,35.08,100,,,fee schedule,100% of bcbs custom fee schedule,38.94,111,,,fee schedule,111% of bcbs custom fee schedule,91.5,50,,73.2,percent of total billed charges,50% of total billed charges,128.1,70,,102.48,percent of total billed charges,70% of total billed charges,88.72,48.48,,70.976,percent of total billed charges,48.48% of total billed charges,13.87,101,,,fee schedule,101% of cms custom fee schedule,88.72,48.48,,70.976,percent of total billed charges,48.48% of total billed charges,128.1,70,,102.48,percent of total billed charges,70% of total billed charges,128.1,70,,102.48,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,88.72,48.48,,70.976,percent of total billed charges,48.48% of total billed charges,164.7,90,,131.76,percent of total billed charges,90% of total billed charges,48.48,164.7,
TACROLIMUS,41009102,CDM,301,RC,80197,HCPCS,outpatient,,,200,120.00,,120,60,,96,percent of total billed charges,60% of total billed charges,96,48,,76.8,percent of total billed charges,48% of total billed charges,41.55,100,,,fee schedule,100% of bcbs custom fee schedule,41.55,100,,,fee schedule,100% of bcbs custom fee schedule,46.12,111,,,fee schedule,111% of bcbs custom fee schedule,100,50,,80,percent of total billed charges,50% of total billed charges,140,70,,112,percent of total billed charges,70% of total billed charges,96.96,48.48,,77.568,percent of total billed charges,48.48% of total billed charges,13.87,101,,,fee schedule,101% of cms custom fee schedule,96.96,48.48,,77.568,percent of total billed charges,48.48% of total billed charges,140,70,,112,percent of total billed charges,70% of total billed charges,140,70,,112,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,96.96,48.48,,77.568,percent of total billed charges,48.48% of total billed charges,180,90,,144,percent of total billed charges,90% of total billed charges,48.48,180,
CHLAMYDIA DNA,41000357,CDM,306,RC,87491,HCPCS,outpatient,,,65,39.00,,39,60,,31.2,percent of total billed charges,60% of total billed charges,31.2,48,,24.96,percent of total billed charges,48% of total billed charges,106.32,100,,,fee schedule,100% of bcbs custom fee schedule,106.32,100,,,fee schedule,100% of bcbs custom fee schedule,118.02,111,,,fee schedule,111% of bcbs custom fee schedule,32.5,50,,26,percent of total billed charges,50% of total billed charges,45.5,70,,36.4,percent of total billed charges,70% of total billed charges,31.51,48.48,,25.208,percent of total billed charges,48.48% of total billed charges,35.44,101,,,fee schedule,101% of cms custom fee schedule,31.51,48.48,,25.208,percent of total billed charges,48.48% of total billed charges,45.5,70,,36.4,percent of total billed charges,70% of total billed charges,45.5,70,,36.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,31.51,48.48,,25.208,percent of total billed charges,48.48% of total billed charges,58.5,90,,46.8,percent of total billed charges,90% of total billed charges,31.51,90,
FOLIC ACID/ FOLATE LEVEL,41001003,CDM,300,RC,82746,HCPCS,outpatient,,,114.5,68.70,,68.7,60,,54.96,percent of total billed charges,60% of total billed charges,54.96,48,,43.968,percent of total billed charges,48% of total billed charges,44.53,100,,,fee schedule,100% of bcbs custom fee schedule,44.53,100,,,fee schedule,100% of bcbs custom fee schedule,49.43,111,,,fee schedule,111% of bcbs custom fee schedule,57.25,50,,45.8,percent of total billed charges,50% of total billed charges,80.15,70,,64.12,percent of total billed charges,70% of total billed charges,55.51,48.48,,44.408,percent of total billed charges,48.48% of total billed charges,14.85,101,,,fee schedule,101% of cms custom fee schedule,55.51,48.48,,44.408,percent of total billed charges,48.48% of total billed charges,80.15,70,,64.12,percent of total billed charges,70% of total billed charges,80.15,70,,64.12,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,55.51,48.48,,44.408,percent of total billed charges,48.48% of total billed charges,103.05,90,,82.44,percent of total billed charges,90% of total billed charges,48.48,103.05,
LIPASE,41000058,CDM,300,RC,83690,HCPCS,outpatient,,,90,54.00,,54,60,,43.2,percent of total billed charges,60% of total billed charges,43.2,48,,34.56,percent of total billed charges,48% of total billed charges,20.86,100,,,fee schedule,100% of bcbs custom fee schedule,20.86,100,,,fee schedule,100% of bcbs custom fee schedule,23.15,111,,,fee schedule,111% of bcbs custom fee schedule,45,50,,36,percent of total billed charges,50% of total billed charges,63,70,,50.4,percent of total billed charges,70% of total billed charges,43.63,48.48,,34.904,percent of total billed charges,48.48% of total billed charges,6.96,101,,,fee schedule,101% of cms custom fee schedule,43.63,48.48,,34.904,percent of total billed charges,48.48% of total billed charges,63,70,,50.4,percent of total billed charges,70% of total billed charges,63,70,,50.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,43.63,48.48,,34.904,percent of total billed charges,48.48% of total billed charges,81,90,,64.8,percent of total billed charges,90% of total billed charges,43.63,90,
D-DIMER,41009065,CDM,305,RC,85379,HCPCS,outpatient,,,187.5,112.50,,112.5,60,,90,percent of total billed charges,60% of total billed charges,90,48,,72,percent of total billed charges,48% of total billed charges,30.83,100,,,fee schedule,100% of bcbs custom fee schedule,30.83,100,,,fee schedule,100% of bcbs custom fee schedule,34.22,111,,,fee schedule,111% of bcbs custom fee schedule,93.75,50,,75,percent of total billed charges,50% of total billed charges,131.25,70,,105,percent of total billed charges,70% of total billed charges,90.9,48.48,,72.72,percent of total billed charges,48.48% of total billed charges,10.28,101,,,fee schedule,101% of cms custom fee schedule,90.9,48.48,,72.72,percent of total billed charges,48.48% of total billed charges,131.25,70,,105,percent of total billed charges,70% of total billed charges,131.25,70,,105,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,90.9,48.48,,72.72,percent of total billed charges,48.48% of total billed charges,168.75,90,,135,percent of total billed charges,90% of total billed charges,48.48,168.75,
RHEUMATOID FACTOR QUAN,41000144,CDM,302,RC,86431,HCPCS,outpatient,,,73.75,44.25,,44.25,60,,35.4,percent of total billed charges,60% of total billed charges,35.4,48,,28.32,percent of total billed charges,48% of total billed charges,17.2,100,,,fee schedule,100% of bcbs custom fee schedule,17.2,100,,,fee schedule,100% of bcbs custom fee schedule,19.09,111,,,fee schedule,111% of bcbs custom fee schedule,36.88,50,,29.504,percent of total billed charges,50% of total billed charges,51.63,70,,41.304,percent of total billed charges,70% of total billed charges,35.75,48.48,,28.6,percent of total billed charges,48.48% of total billed charges,5.73,101,,,fee schedule,101% of cms custom fee schedule,35.75,48.48,,28.6,percent of total billed charges,48.48% of total billed charges,51.63,70,,41.304,percent of total billed charges,70% of total billed charges,51.63,70,,41.304,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,35.75,48.48,,28.6,percent of total billed charges,48.48% of total billed charges,66.38,90,,53.104,percent of total billed charges,90% of total billed charges,35.75,90,
PREALBUMIN,41001101,CDM,301,RC,84134,HCPCS,outpatient,,,115,69.00,,69,60,,55.2,percent of total billed charges,60% of total billed charges,55.2,48,,44.16,percent of total billed charges,48% of total billed charges,16.9,100,,,fee schedule,100% of bcbs custom fee schedule,16.9,100,,,fee schedule,100% of bcbs custom fee schedule,18.76,111,,,fee schedule,111% of bcbs custom fee schedule,57.5,50,,46,percent of total billed charges,50% of total billed charges,80.5,70,,64.4,percent of total billed charges,70% of total billed charges,55.75,48.48,,44.6,percent of total billed charges,48.48% of total billed charges,14.74,101,,,fee schedule,101% of cms custom fee schedule,55.75,48.48,,44.6,percent of total billed charges,48.48% of total billed charges,80.5,70,,64.4,percent of total billed charges,70% of total billed charges,80.5,70,,64.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,55.75,48.48,,44.6,percent of total billed charges,48.48% of total billed charges,103.5,90,,82.8,percent of total billed charges,90% of total billed charges,48.48,103.5,
VITAMIN E LEVEL/TOCOPHEROL,41001141,CDM,300,RC,84446,HCPCS,outpatient,,,140,84.00,,84,60,,67.2,percent of total billed charges,60% of total billed charges,67.2,48,,53.76,percent of total billed charges,48% of total billed charges,42.95,100,,,fee schedule,100% of bcbs custom fee schedule,42.95,100,,,fee schedule,100% of bcbs custom fee schedule,47.67,111,,,fee schedule,111% of bcbs custom fee schedule,70,50,,56,percent of total billed charges,50% of total billed charges,98,70,,78.4,percent of total billed charges,70% of total billed charges,67.87,48.48,,54.296,percent of total billed charges,48.48% of total billed charges,14.32,101,,,fee schedule,101% of cms custom fee schedule,67.87,48.48,,54.296,percent of total billed charges,48.48% of total billed charges,98,70,,78.4,percent of total billed charges,70% of total billed charges,98,70,,78.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,67.87,48.48,,54.296,percent of total billed charges,48.48% of total billed charges,126,90,,100.8,percent of total billed charges,90% of total billed charges,48.48,126,
CULTURE STOOL AEROBIC,41000503,CDM,300,RC,87045,HCPCS,outpatient,,,112.5,67.50,,67.5,60,,54,percent of total billed charges,60% of total billed charges,54,48,,43.2,percent of total billed charges,48% of total billed charges,28.57,100,,,fee schedule,100% of bcbs custom fee schedule,28.57,100,,,fee schedule,100% of bcbs custom fee schedule,31.71,111,,,fee schedule,111% of bcbs custom fee schedule,56.25,50,,45,percent of total billed charges,50% of total billed charges,78.75,70,,63,percent of total billed charges,70% of total billed charges,54.54,48.48,,43.632,percent of total billed charges,48.48% of total billed charges,9.53,101,,,fee schedule,101% of cms custom fee schedule,54.54,48.48,,43.632,percent of total billed charges,48.48% of total billed charges,78.75,70,,63,percent of total billed charges,70% of total billed charges,78.75,70,,63,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,54.54,48.48,,43.632,percent of total billed charges,48.48% of total billed charges,101.25,90,,81,percent of total billed charges,90% of total billed charges,48.48,101.25,
PROSTATE SPECIFIC ANTIGEN,,,300,RC,,,outpatient,,,125.5,75.30,,75.3,60,,60.24,percent of total billed charges,60% of total billed charges,60.24,48,,48.192,percent of total billed charges,48% of total billed charges,62.75,50,,50.2,percent of total billed charges,50% of total billed charges,62.75,50,,50.2,percent of total billed charges,50% of total billed charges,62.75,50,,50.2,percent of total billed charges,50% of total billed charges,62.75,50,,50.2,percent of total billed charges,50% of total billed charges,87.85,70,,70.28,percent of total billed charges,70% of total billed charges,60.84,48.48,,48.672,percent of total billed charges,48.48% of total billed charges,60.84,48.48,,48.672,percent of total billed charges,48.48% of total billed charges,60.84,48.48,,48.672,percent of total billed charges,48.48% of total billed charges,87.85,70,,70.28,percent of total billed charges,70% of total billed charges,87.85,70,,70.28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,60.84,48.48,,48.672,percent of total billed charges,48.48% of total billed charges,112.95,90,,90.36,percent of total billed charges,90% of total billed charges,48.48,112.95,
ACTIVATED PROTEIN C RESISTANCE,41000571,CDM,300,RC,85307,HCPCS,outpatient,,,159,95.40,,95.4,60,,76.32,percent of total billed charges,60% of total billed charges,76.32,48,,61.056,percent of total billed charges,48% of total billed charges,46.41,100,,,fee schedule,100% of bcbs custom fee schedule,46.41,100,,,fee schedule,100% of bcbs custom fee schedule,51.52,111,,,fee schedule,111% of bcbs custom fee schedule,79.5,50,,63.6,percent of total billed charges,50% of total billed charges,111.3,70,,89.04,percent of total billed charges,70% of total billed charges,77.08,48.48,,61.664,percent of total billed charges,48.48% of total billed charges,15.47,101,,,fee schedule,101% of cms custom fee schedule,77.08,48.48,,61.664,percent of total billed charges,48.48% of total billed charges,111.3,70,,89.04,percent of total billed charges,70% of total billed charges,111.3,70,,89.04,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,77.08,48.48,,61.664,percent of total billed charges,48.48% of total billed charges,143.1,90,,114.48,percent of total billed charges,90% of total billed charges,48.48,143.1,
FACTOR V LEIDEN MUTATION,41000380,CDM,300,RC,81241,HCPCS,outpatient,,,401.5,240.90,,240.9,60,,192.72,percent of total billed charges,60% of total billed charges,192.72,48,,154.176,percent of total billed charges,48% of total billed charges,138.03,100,,,fee schedule,100% of bcbs custom fee schedule,138.03,100,,,fee schedule,100% of bcbs custom fee schedule,153.21,111,,,fee schedule,111% of bcbs custom fee schedule,200.75,50,,160.6,percent of total billed charges,50% of total billed charges,281.05,70,,224.84,percent of total billed charges,70% of total billed charges,194.65,48.48,,155.72,percent of total billed charges,48.48% of total billed charges,74.1,101,,,fee schedule,101% of cms custom fee schedule,194.65,48.48,,155.72,percent of total billed charges,48.48% of total billed charges,281.05,70,,224.84,percent of total billed charges,70% of total billed charges,281.05,70,,224.84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,194.65,48.48,,155.72,percent of total billed charges,48.48% of total billed charges,361.35,90,,289.08,percent of total billed charges,90% of total billed charges,48.48,361.35,
"LACTOFERRIN, QUANTITATIVE STOOL",,,300,RC,83630,HCPCS,outpatient,,,190,114.00,,114,60,,91.2,percent of total billed charges,60% of total billed charges,91.2,48,,72.96,percent of total billed charges,48% of total billed charges,34.94,100,,,fee schedule,100% of bcbs custom fee schedule,34.94,100,,,fee schedule,100% of bcbs custom fee schedule,38.78,111,,,fee schedule,111% of bcbs custom fee schedule,95,50,,76,percent of total billed charges,50% of total billed charges,133,70,,106.4,percent of total billed charges,70% of total billed charges,92.11,48.48,,73.688,percent of total billed charges,48.48% of total billed charges,19.9,101,,,fee schedule,101% of cms custom fee schedule,92.11,48.48,,73.688,percent of total billed charges,48.48% of total billed charges,133,70,,106.4,percent of total billed charges,70% of total billed charges,133,70,,106.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,92.11,48.48,,73.688,percent of total billed charges,48.48% of total billed charges,171,90,,136.8,percent of total billed charges,90% of total billed charges,48.48,171,
HELICOBACTER PYLORI UREA BREATH,,,300,RC,83013,HCPCS,outpatient,,,160,96.00,,96,60,,76.8,percent of total billed charges,60% of total billed charges,76.8,48,,61.44,percent of total billed charges,48% of total billed charges,87.66,100,,,fee schedule,100% of bcbs custom fee schedule,87.66,100,,,fee schedule,100% of bcbs custom fee schedule,97.3,111,,,fee schedule,111% of bcbs custom fee schedule,80,50,,64,percent of total billed charges,50% of total billed charges,112,70,,89.6,percent of total billed charges,70% of total billed charges,77.57,48.48,,62.056,percent of total billed charges,48.48% of total billed charges,68.03,101,,,fee schedule,101% of cms custom fee schedule,77.57,48.48,,62.056,percent of total billed charges,48.48% of total billed charges,112,70,,89.6,percent of total billed charges,70% of total billed charges,112,70,,89.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,77.57,48.48,,62.056,percent of total billed charges,48.48% of total billed charges,144,90,,115.2,percent of total billed charges,90% of total billed charges,48.48,144,
IMMUNOFIXATION ELECTROPHORESIS URINE/CSF,,,300,RC,86335,HCPCS,outpatient,,,245.5,147.30,,147.3,60,,117.84,percent of total billed charges,60% of total billed charges,117.84,48,,94.272,percent of total billed charges,48% of total billed charges,88.88,100,,,fee schedule,100% of bcbs custom fee schedule,88.88,100,,,fee schedule,100% of bcbs custom fee schedule,98.66,111,,,fee schedule,111% of bcbs custom fee schedule,122.75,50,,98.2,percent of total billed charges,50% of total billed charges,171.85,70,,137.48,percent of total billed charges,70% of total billed charges,119.02,48.48,,95.216,percent of total billed charges,48.48% of total billed charges,29.64,101,,,fee schedule,101% of cms custom fee schedule,119.02,48.48,,95.216,percent of total billed charges,48.48% of total billed charges,171.85,70,,137.48,percent of total billed charges,70% of total billed charges,171.85,70,,137.48,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,119.02,48.48,,95.216,percent of total billed charges,48.48% of total billed charges,220.95,90,,176.76,percent of total billed charges,90% of total billed charges,48.48,220.95,
LAMOTRIGINE LEVEL,,,300,RC,80175,HCPCS,outpatient,,,275,165.00,,165,60,,132,percent of total billed charges,60% of total billed charges,132,48,,105.6,percent of total billed charges,48% of total billed charges,33.1,100,,,fee schedule,100% of bcbs custom fee schedule,33.1,100,,,fee schedule,100% of bcbs custom fee schedule,36.74,111,,,fee schedule,111% of bcbs custom fee schedule,137.5,50,,110,percent of total billed charges,50% of total billed charges,192.5,70,,154,percent of total billed charges,70% of total billed charges,133.32,48.48,,106.656,percent of total billed charges,48.48% of total billed charges,13.38,101,,,fee schedule,101% of cms custom fee schedule,133.32,48.48,,106.656,percent of total billed charges,48.48% of total billed charges,192.5,70,,154,percent of total billed charges,70% of total billed charges,192.5,70,,154,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,133.32,48.48,,106.656,percent of total billed charges,48.48% of total billed charges,247.5,90,,198,percent of total billed charges,90% of total billed charges,48.48,247.5,
RUSSELL VENOM VIPER DILUTED,41000230,CDM,300,RC,85613,HCPCS,outpatient,,,90,54.00,,54,60,,43.2,percent of total billed charges,60% of total billed charges,43.2,48,,34.56,percent of total billed charges,48% of total billed charges,28.98,100,,,fee schedule,100% of bcbs custom fee schedule,28.98,100,,,fee schedule,100% of bcbs custom fee schedule,32.17,111,,,fee schedule,111% of bcbs custom fee schedule,45,50,,36,percent of total billed charges,50% of total billed charges,63,70,,50.4,percent of total billed charges,70% of total billed charges,43.63,48.48,,34.904,percent of total billed charges,48.48% of total billed charges,9.68,101,,,fee schedule,101% of cms custom fee schedule,43.63,48.48,,34.904,percent of total billed charges,48.48% of total billed charges,63,70,,50.4,percent of total billed charges,70% of total billed charges,63,70,,50.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,43.63,48.48,,34.904,percent of total billed charges,48.48% of total billed charges,81,90,,64.8,percent of total billed charges,90% of total billed charges,43.63,90,
Oxycodone confirmation,,,300,RC,80365,HCPCS,outpatient,,,62.5,37.50,,37.5,60,,30,percent of total billed charges,60% of total billed charges,30,48,,24,percent of total billed charges,48% of total billed charges,17.66,100,,,fee schedule,100% of bcbs custom fee schedule,17.66,100,,,fee schedule,100% of bcbs custom fee schedule,19.6,111,,,fee schedule,111% of bcbs custom fee schedule,31.25,50,,25,percent of total billed charges,50% of total billed charges,43.75,70,,35,percent of total billed charges,70% of total billed charges,30.3,48.48,,24.24,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,30.3,48.48,,24.24,percent of total billed charges,48.48% of total billed charges,43.75,70,,35,percent of total billed charges,70% of total billed charges,43.75,70,,35,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,30.3,48.48,,24.24,percent of total billed charges,48.48% of total billed charges,56.25,90,,45,percent of total billed charges,90% of total billed charges,30.3,90,
ANTIMULLERIAN HORMONE,41000540,CDM,300,RC,83520,HCPCS,outpatient,,,230,138.00,,138,60,,110.4,percent of total billed charges,60% of total billed charges,110.4,48,,88.32,percent of total billed charges,48% of total billed charges,39.22,100,,,fee schedule,100% of bcbs custom fee schedule,39.22,100,,,fee schedule,100% of bcbs custom fee schedule,43.53,111,,,fee schedule,111% of bcbs custom fee schedule,115,50,,92,percent of total billed charges,50% of total billed charges,161,70,,128.8,percent of total billed charges,70% of total billed charges,111.5,48.48,,89.2,percent of total billed charges,48.48% of total billed charges,17.44,101,,,fee schedule,101% of cms custom fee schedule,111.5,48.48,,89.2,percent of total billed charges,48.48% of total billed charges,161,70,,128.8,percent of total billed charges,70% of total billed charges,161,70,,128.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,111.5,48.48,,89.2,percent of total billed charges,48.48% of total billed charges,207,90,,165.6,percent of total billed charges,90% of total billed charges,48.48,207,
17-HYDROXYPROGESTERONE,41001071,CDM,300,RC,83498,HCPCS,outpatient,,,166,99.60,,99.6,60,,79.68,percent of total billed charges,60% of total billed charges,79.68,48,,63.744,percent of total billed charges,48% of total billed charges,82.28,100,,,fee schedule,100% of bcbs custom fee schedule,82.28,100,,,fee schedule,100% of bcbs custom fee schedule,91.33,111,,,fee schedule,111% of bcbs custom fee schedule,83,50,,66.4,percent of total billed charges,50% of total billed charges,116.2,70,,92.96,percent of total billed charges,70% of total billed charges,80.48,48.48,,64.384,percent of total billed charges,48.48% of total billed charges,27.44,101,,,fee schedule,101% of cms custom fee schedule,80.48,48.48,,64.384,percent of total billed charges,48.48% of total billed charges,116.2,70,,92.96,percent of total billed charges,70% of total billed charges,116.2,70,,92.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,80.48,48.48,,64.384,percent of total billed charges,48.48% of total billed charges,149.4,90,,119.52,percent of total billed charges,90% of total billed charges,48.48,149.4,
"Trichinella Antibody (IgG), ELISA",,,300,RC,86784,HCPCS,outpatient,,,120,72.00,,72,60,,57.6,percent of total billed charges,60% of total billed charges,57.6,48,,46.08,percent of total billed charges,48% of total billed charges,14.09,100,,,fee schedule,100% of bcbs custom fee schedule,14.09,100,,,fee schedule,100% of bcbs custom fee schedule,15.64,111,,,fee schedule,111% of bcbs custom fee schedule,60,50,,48,percent of total billed charges,50% of total billed charges,84,70,,67.2,percent of total billed charges,70% of total billed charges,58.18,48.48,,46.544,percent of total billed charges,48.48% of total billed charges,12.69,101,,,fee schedule,101% of cms custom fee schedule,58.18,48.48,,46.544,percent of total billed charges,48.48% of total billed charges,84,70,,67.2,percent of total billed charges,70% of total billed charges,84,70,,67.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,58.18,48.48,,46.544,percent of total billed charges,48.48% of total billed charges,108,90,,86.4,percent of total billed charges,90% of total billed charges,48.48,108,
CA125,41000468,CDM,300,RC,86304,HCPCS,outpatient,,,125,75.00,,75,60,,60,percent of total billed charges,60% of total billed charges,60,48,,48,percent of total billed charges,48% of total billed charges,63.02,100,,,fee schedule,100% of bcbs custom fee schedule,63.02,100,,,fee schedule,100% of bcbs custom fee schedule,69.95,111,,,fee schedule,111% of bcbs custom fee schedule,62.5,50,,50,percent of total billed charges,50% of total billed charges,87.5,70,,70,percent of total billed charges,70% of total billed charges,60.6,48.48,,48.48,percent of total billed charges,48.48% of total billed charges,21.02,101,,,fee schedule,101% of cms custom fee schedule,60.6,48.48,,48.48,percent of total billed charges,48.48% of total billed charges,87.5,70,,70,percent of total billed charges,70% of total billed charges,87.5,70,,70,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,60.6,48.48,,48.48,percent of total billed charges,48.48% of total billed charges,112.5,90,,90,percent of total billed charges,90% of total billed charges,48.48,112.5,
TPMT ENZYME ACTIVITY/MERCAPTOPURINE TOX,41001169,CDM,300,RC,82657,HCPCS,outpatient,,,240,144.00,,144,60,,115.2,percent of total billed charges,60% of total billed charges,115.2,48,,92.16,percent of total billed charges,48% of total billed charges,54.69,100,,,fee schedule,100% of bcbs custom fee schedule,54.69,100,,,fee schedule,100% of bcbs custom fee schedule,60.71,111,,,fee schedule,111% of bcbs custom fee schedule,120,50,,96,percent of total billed charges,50% of total billed charges,168,70,,134.4,percent of total billed charges,70% of total billed charges,116.35,48.48,,93.08,percent of total billed charges,48.48% of total billed charges,22.39,101,,,fee schedule,101% of cms custom fee schedule,116.35,48.48,,93.08,percent of total billed charges,48.48% of total billed charges,168,70,,134.4,percent of total billed charges,70% of total billed charges,168,70,,134.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,116.35,48.48,,93.08,percent of total billed charges,48.48% of total billed charges,216,90,,172.8,percent of total billed charges,90% of total billed charges,48.48,216,
MOLECULAR PATHOLOGY PROCEDURE LEVEL2,,,300,RC,81401,HCPCS,outpatient,,,380,228.00,,228,60,,182.4,percent of total billed charges,60% of total billed charges,182.4,48,,145.92,percent of total billed charges,48% of total billed charges,250.66,100,,,fee schedule,100% of bcbs custom fee schedule,250.66,100,,,fee schedule,100% of bcbs custom fee schedule,278.23,111,,,fee schedule,111% of bcbs custom fee schedule,190,50,,152,percent of total billed charges,50% of total billed charges,266,70,,212.8,percent of total billed charges,70% of total billed charges,184.22,48.48,,147.376,percent of total billed charges,48.48% of total billed charges,138.37,101,,,fee schedule,101% of cms custom fee schedule,184.22,48.48,,147.376,percent of total billed charges,48.48% of total billed charges,266,70,,212.8,percent of total billed charges,70% of total billed charges,266,70,,212.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,184.22,48.48,,147.376,percent of total billed charges,48.48% of total billed charges,342,90,,273.6,percent of total billed charges,90% of total billed charges,48.48,342,
"West Nile Virus Antibody, IgM",,,300,RC,86788,HCPCS,outpatient,,,222.5,133.50,,133.5,60,,106.8,percent of total billed charges,60% of total billed charges,106.8,48,,85.44,percent of total billed charges,48% of total billed charges,43.07,100,,,fee schedule,100% of bcbs custom fee schedule,43.07,100,,,fee schedule,100% of bcbs custom fee schedule,47.81,111,,,fee schedule,111% of bcbs custom fee schedule,111.25,50,,89,percent of total billed charges,50% of total billed charges,155.75,70,,124.6,percent of total billed charges,70% of total billed charges,107.87,48.48,,86.296,percent of total billed charges,48.48% of total billed charges,17.02,101,,,fee schedule,101% of cms custom fee schedule,107.87,48.48,,86.296,percent of total billed charges,48.48% of total billed charges,155.75,70,,124.6,percent of total billed charges,70% of total billed charges,155.75,70,,124.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,107.87,48.48,,86.296,percent of total billed charges,48.48% of total billed charges,200.25,90,,160.2,percent of total billed charges,90% of total billed charges,48.48,200.25,
"West Nile Virus Antibody, IgG",,,300,RC,86789,HCPCS,outpatient,,,222.5,133.50,,133.5,60,,106.8,percent of total billed charges,60% of total billed charges,106.8,48,,85.44,percent of total billed charges,48% of total billed charges,36.79,100,,,fee schedule,100% of bcbs custom fee schedule,36.79,100,,,fee schedule,100% of bcbs custom fee schedule,40.84,111,,,fee schedule,111% of bcbs custom fee schedule,111.25,50,,89,percent of total billed charges,50% of total billed charges,155.75,70,,124.6,percent of total billed charges,70% of total billed charges,107.87,48.48,,86.296,percent of total billed charges,48.48% of total billed charges,14.53,101,,,fee schedule,101% of cms custom fee schedule,107.87,48.48,,86.296,percent of total billed charges,48.48% of total billed charges,155.75,70,,124.6,percent of total billed charges,70% of total billed charges,155.75,70,,124.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,107.87,48.48,,86.296,percent of total billed charges,48.48% of total billed charges,200.25,90,,160.2,percent of total billed charges,90% of total billed charges,48.48,200.25,
Herpes Simplex PCR,,,300,RC,87529,HCPCS,outpatient,,,125,75.00,91,75,60,,60,percent of total billed charges,60% of total billed charges,60,48,,48,percent of total billed charges,48% of total billed charges,106.32,100,,,fee schedule,100% of bcbs custom fee schedule,106.32,100,,,fee schedule,100% of bcbs custom fee schedule,118.02,111,,,fee schedule,111% of bcbs custom fee schedule,62.5,50,,50,percent of total billed charges,50% of total billed charges,87.5,70,,70,percent of total billed charges,70% of total billed charges,60.6,48.48,,48.48,percent of total billed charges,48.48% of total billed charges,35.44,101,,,fee schedule,101% of cms custom fee schedule,60.6,48.48,,48.48,percent of total billed charges,48.48% of total billed charges,87.5,70,,70,percent of total billed charges,70% of total billed charges,87.5,70,,70,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,60.6,48.48,,48.48,percent of total billed charges,48.48% of total billed charges,112.5,90,,90,percent of total billed charges,90% of total billed charges,48.48,112.5,
CA 19-9,41000075,CDM,300,RC,86301,HCPCS,outpatient,,,125,75.00,,75,60,,60,percent of total billed charges,60% of total billed charges,60,48,,48,percent of total billed charges,48% of total billed charges,63.02,100,,,fee schedule,100% of bcbs custom fee schedule,63.02,100,,,fee schedule,100% of bcbs custom fee schedule,69.95,111,,,fee schedule,111% of bcbs custom fee schedule,62.5,50,,50,percent of total billed charges,50% of total billed charges,87.5,70,,70,percent of total billed charges,70% of total billed charges,60.6,48.48,,48.48,percent of total billed charges,48.48% of total billed charges,21.02,101,,,fee schedule,101% of cms custom fee schedule,60.6,48.48,,48.48,percent of total billed charges,48.48% of total billed charges,87.5,70,,70,percent of total billed charges,70% of total billed charges,87.5,70,,70,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,60.6,48.48,,48.48,percent of total billed charges,48.48% of total billed charges,112.5,90,,90,percent of total billed charges,90% of total billed charges,48.48,112.5,
HISTOPLASMA ANTIBODY,41000399,CDM,300,RC,86698,HCPCS,outpatient,,,160,96.00,,96,60,,76.8,percent of total billed charges,60% of total billed charges,76.8,48,,61.44,percent of total billed charges,48% of total billed charges,37.84,100,,,fee schedule,100% of bcbs custom fee schedule,37.84,100,,,fee schedule,100% of bcbs custom fee schedule,42,111,,,fee schedule,111% of bcbs custom fee schedule,80,50,,64,percent of total billed charges,50% of total billed charges,112,70,,89.6,percent of total billed charges,70% of total billed charges,77.57,48.48,,62.056,percent of total billed charges,48.48% of total billed charges,13.93,101,,,fee schedule,101% of cms custom fee schedule,77.57,48.48,,62.056,percent of total billed charges,48.48% of total billed charges,112,70,,89.6,percent of total billed charges,70% of total billed charges,112,70,,89.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,77.57,48.48,,62.056,percent of total billed charges,48.48% of total billed charges,144,90,,115.2,percent of total billed charges,90% of total billed charges,48.48,144,
Infectious Agent DNA/RNA Influenzae,41009164,CDM,300,RC,87502,HCPCS,outpatient,,,150,90.00,QW,90,60,,72,percent of total billed charges,60% of total billed charges,72,48,,57.6,percent of total billed charges,48% of total billed charges,219.11,100,,,fee schedule,100% of bcbs custom fee schedule,219.11,100,,,fee schedule,100% of bcbs custom fee schedule,243.21,111,,,fee schedule,111% of bcbs custom fee schedule,75,50,,60,percent of total billed charges,50% of total billed charges,105,70,,84,percent of total billed charges,70% of total billed charges,72.72,48.48,,58.176,percent of total billed charges,48.48% of total billed charges,96.76,101,,,fee schedule,101% of cms custom fee schedule,72.72,48.48,,58.176,percent of total billed charges,48.48% of total billed charges,105,70,,84,percent of total billed charges,70% of total billed charges,105,70,,84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,72.72,48.48,,58.176,percent of total billed charges,48.48% of total billed charges,135,90,,108,percent of total billed charges,90% of total billed charges,48.48,135,
"BLASTOMYCES ANTIBODIES, IMMUNO DIFFUSION",41000490,CDM,300,RC,86612,HCPCS,outpatient,,,125,75.00,,75,60,,60,percent of total billed charges,60% of total billed charges,60,48,,48,percent of total billed charges,48% of total billed charges,39.08,100,,,fee schedule,100% of bcbs custom fee schedule,39.08,100,,,fee schedule,100% of bcbs custom fee schedule,43.38,111,,,fee schedule,111% of bcbs custom fee schedule,62.5,50,,50,percent of total billed charges,50% of total billed charges,87.5,70,,70,percent of total billed charges,70% of total billed charges,60.6,48.48,,48.48,percent of total billed charges,48.48% of total billed charges,13.03,101,,,fee schedule,101% of cms custom fee schedule,60.6,48.48,,48.48,percent of total billed charges,48.48% of total billed charges,87.5,70,,70,percent of total billed charges,70% of total billed charges,87.5,70,,70,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,60.6,48.48,,48.48,percent of total billed charges,48.48% of total billed charges,112.5,90,,90,percent of total billed charges,90% of total billed charges,48.48,112.5,
"Legionella Antigen, EIA, Urine",41000373,CDM,300,RC,87449,HCPCS,outpatient,,,75,45.00,91,45,60,,36,percent of total billed charges,60% of total billed charges,36,48,,28.8,percent of total billed charges,48% of total billed charges,36.33,100,,,fee schedule,100% of bcbs custom fee schedule,36.33,100,,,fee schedule,100% of bcbs custom fee schedule,40.33,111,,,fee schedule,111% of bcbs custom fee schedule,37.5,50,,30,percent of total billed charges,50% of total billed charges,52.5,70,,42,percent of total billed charges,70% of total billed charges,36.36,48.48,,29.088,percent of total billed charges,48.48% of total billed charges,12.1,101,,,fee schedule,101% of cms custom fee schedule,36.36,48.48,,29.088,percent of total billed charges,48.48% of total billed charges,52.5,70,,42,percent of total billed charges,70% of total billed charges,52.5,70,,42,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,36.36,48.48,,29.088,percent of total billed charges,48.48% of total billed charges,67.5,90,,54,percent of total billed charges,90% of total billed charges,36.36,90,
HEPATITIS A IGM,41000911,CDM,300,RC,86709,HCPCS,outpatient,,,58,34.80,,34.8,60,,27.84,percent of total billed charges,60% of total billed charges,27.84,48,,22.272,percent of total billed charges,48% of total billed charges,34.1,100,,,fee schedule,100% of bcbs custom fee schedule,34.1,100,,,fee schedule,100% of bcbs custom fee schedule,37.85,111,,,fee schedule,111% of bcbs custom fee schedule,29,50,,23.2,percent of total billed charges,50% of total billed charges,40.6,70,,32.48,percent of total billed charges,70% of total billed charges,28.12,48.48,,22.496,percent of total billed charges,48.48% of total billed charges,11.37,101,,,fee schedule,101% of cms custom fee schedule,28.12,48.48,,22.496,percent of total billed charges,48.48% of total billed charges,40.6,70,,32.48,percent of total billed charges,70% of total billed charges,40.6,70,,32.48,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,28.12,48.48,,22.496,percent of total billed charges,48.48% of total billed charges,52.2,90,,41.76,percent of total billed charges,90% of total billed charges,28.12,90,
SEX HORMONE BINDING GLOBULIN,41000780,CDM,300,RC,84270,HCPCS,outpatient,,,56,33.60,,33.6,60,,26.88,percent of total billed charges,60% of total billed charges,26.88,48,,21.504,percent of total billed charges,48% of total billed charges,65.82,100,,,fee schedule,100% of bcbs custom fee schedule,65.82,100,,,fee schedule,100% of bcbs custom fee schedule,73.06,111,,,fee schedule,111% of bcbs custom fee schedule,28,50,,22.4,percent of total billed charges,50% of total billed charges,39.2,70,,31.36,percent of total billed charges,70% of total billed charges,27.15,48.48,,21.72,percent of total billed charges,48.48% of total billed charges,21.95,101,,,fee schedule,101% of cms custom fee schedule,27.15,48.48,,21.72,percent of total billed charges,48.48% of total billed charges,39.2,70,,31.36,percent of total billed charges,70% of total billed charges,39.2,70,,31.36,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,27.15,48.48,,21.72,percent of total billed charges,48.48% of total billed charges,50.4,90,,40.32,percent of total billed charges,90% of total billed charges,27.15,90,
"HIV-1 RNA, RT-PCR",,,300,RC,87535,HCPCS,outpatient,,,375,225.00,,225,60,,180,percent of total billed charges,60% of total billed charges,180,48,,144,percent of total billed charges,48% of total billed charges,106.32,100,,,fee schedule,100% of bcbs custom fee schedule,106.32,100,,,fee schedule,100% of bcbs custom fee schedule,118.02,111,,,fee schedule,111% of bcbs custom fee schedule,187.5,50,,150,percent of total billed charges,50% of total billed charges,262.5,70,,210,percent of total billed charges,70% of total billed charges,181.8,48.48,,145.44,percent of total billed charges,48.48% of total billed charges,35.44,101,,,fee schedule,101% of cms custom fee schedule,181.8,48.48,,145.44,percent of total billed charges,48.48% of total billed charges,262.5,70,,210,percent of total billed charges,70% of total billed charges,262.5,70,,210,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,181.8,48.48,,145.44,percent of total billed charges,48.48% of total billed charges,337.5,90,,270,percent of total billed charges,90% of total billed charges,48.48,337.5,
Vascular Endothelial Growth Factor (VEGF),41000540,CDM,300,RC,83520,HCPCS,outpatient,,,300,180.00,,180,60,,144,percent of total billed charges,60% of total billed charges,144,48,,115.2,percent of total billed charges,48% of total billed charges,39.22,100,,,fee schedule,100% of bcbs custom fee schedule,39.22,100,,,fee schedule,100% of bcbs custom fee schedule,43.53,111,,,fee schedule,111% of bcbs custom fee schedule,150,50,,120,percent of total billed charges,50% of total billed charges,210,70,,168,percent of total billed charges,70% of total billed charges,145.44,48.48,,116.352,percent of total billed charges,48.48% of total billed charges,17.44,101,,,fee schedule,101% of cms custom fee schedule,145.44,48.48,,116.352,percent of total billed charges,48.48% of total billed charges,210,70,,168,percent of total billed charges,70% of total billed charges,210,70,,168,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,145.44,48.48,,116.352,percent of total billed charges,48.48% of total billed charges,270,90,,216,percent of total billed charges,90% of total billed charges,48.48,270,
"DRUG SCREEN URINE, RAPID",41000275,CDM,300,RC,80305,HCPCS,outpatient,,,100,60.00,,60,60,,48,percent of total billed charges,60% of total billed charges,48,48,,38.4,percent of total billed charges,48% of total billed charges,27.19,100,,,fee schedule,100% of bcbs custom fee schedule,27.19,100,,,fee schedule,100% of bcbs custom fee schedule,30.18,111,,,fee schedule,111% of bcbs custom fee schedule,50,50,,40,percent of total billed charges,50% of total billed charges,70,70,,56,percent of total billed charges,70% of total billed charges,48.48,48.48,,38.784,percent of total billed charges,48.48% of total billed charges,12.73,101,,,fee schedule,101% of cms custom fee schedule,48.48,48.48,,38.784,percent of total billed charges,48.48% of total billed charges,70,70,,56,percent of total billed charges,70% of total billed charges,70,70,,56,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,48.48,48.48,,38.784,percent of total billed charges,48.48% of total billed charges,90,90,,72,percent of total billed charges,90% of total billed charges,48.48,90,
CAPILLARY BLOOD DRAW,41000371,CDM,300,RC,36416,HCPCS,outpatient,,,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,1.16,100,,,fee schedule,100% of bcbs custom fee schedule,1.16,100,,,fee schedule,100% of bcbs custom fee schedule,1.29,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
TISSUE TRANSGLUTAMINASE ANTIBODY,,,300,RC,86364,HCPCS,outpatient,,,140,84.00,91,84,60,,67.2,percent of total billed charges,60% of total billed charges,67.2,48,,53.76,percent of total billed charges,48% of total billed charges,70,50,,56,percent of total billed charges,50% of total billed charges,70,50,,56,percent of total billed charges,50% of total billed charges,70,50,,56,percent of total billed charges,50% of total billed charges,70,50,,56,percent of total billed charges,50% of total billed charges,98,70,,78.4,percent of total billed charges,70% of total billed charges,67.87,48.48,,54.296,percent of total billed charges,48.48% of total billed charges,11.65,101,,,fee schedule,101% of cms custom fee schedule,67.87,48.48,,54.296,percent of total billed charges,48.48% of total billed charges,98,70,,78.4,percent of total billed charges,70% of total billed charges,98,70,,78.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,67.87,48.48,,54.296,percent of total billed charges,48.48% of total billed charges,126,90,,100.8,percent of total billed charges,90% of total billed charges,48.48,126,
"ANTIBODY IDENTIFICATION, LEUKOCYTE ANTI",,,300,RC,86021,HCPCS,outpatient,,,281.25,168.75,91,168.75,60,,135,percent of total billed charges,60% of total billed charges,135,48,,108,percent of total billed charges,48% of total billed charges,45.58,100,,,fee schedule,100% of bcbs custom fee schedule,45.58,100,,,fee schedule,100% of bcbs custom fee schedule,50.59,111,,,fee schedule,111% of bcbs custom fee schedule,140.63,50,,112.504,percent of total billed charges,50% of total billed charges,196.88,70,,157.504,percent of total billed charges,70% of total billed charges,136.35,48.48,,109.08,percent of total billed charges,48.48% of total billed charges,15.2,101,,,fee schedule,101% of cms custom fee schedule,136.35,48.48,,109.08,percent of total billed charges,48.48% of total billed charges,196.88,70,,157.504,percent of total billed charges,70% of total billed charges,196.88,70,,157.504,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,136.35,48.48,,109.08,percent of total billed charges,48.48% of total billed charges,253.13,90,,202.504,percent of total billed charges,90% of total billed charges,48.48,253.13,
"FLOW CYTOMETRY, 1 MARKER",41001162,CDM,311,RC,88184,HCPCS,outpatient,,,300,180.00,,180,60,,144,percent of total billed charges,60% of total billed charges,144,48,,115.2,percent of total billed charges,48% of total billed charges,113.87,100,,,fee schedule,100% of bcbs custom fee schedule,113.87,100,,,fee schedule,100% of bcbs custom fee schedule,126.4,111,,,fee schedule,111% of bcbs custom fee schedule,150,50,,120,percent of total billed charges,50% of total billed charges,210,70,,168,percent of total billed charges,70% of total billed charges,145.44,48.48,,116.352,percent of total billed charges,48.48% of total billed charges,79.46,116.15,,,fee schedule,116.51% of cms physician fee schedule,145.44,48.48,,116.352,percent of total billed charges,48.48% of total billed charges,210,70,,168,percent of total billed charges,70% of total billed charges,210,70,,168,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,145.44,48.48,,116.352,percent of total billed charges,48.48% of total billed charges,270,90,,216,percent of total billed charges,90% of total billed charges,48.48,270,
"FLOW CYTOMETRY, ADD-ON",41001163,CDM,311,RC,88185,HCPCS,outpatient,,,152,91.20,,91.2,60,,72.96,percent of total billed charges,60% of total billed charges,72.96,48,,58.368,percent of total billed charges,48% of total billed charges,56.29,100,,,fee schedule,100% of bcbs custom fee schedule,56.29,100,,,fee schedule,100% of bcbs custom fee schedule,62.48,111,,,fee schedule,111% of bcbs custom fee schedule,76,50,,60.8,percent of total billed charges,50% of total billed charges,106.4,70,,85.12,percent of total billed charges,70% of total billed charges,73.69,48.48,,58.952,percent of total billed charges,48.48% of total billed charges,24.04,116.15,,,fee schedule,116.51% of cms physician fee schedule,73.69,48.48,,58.952,percent of total billed charges,48.48% of total billed charges,106.4,70,,85.12,percent of total billed charges,70% of total billed charges,106.4,70,,85.12,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,73.69,48.48,,58.952,percent of total billed charges,48.48% of total billed charges,136.8,90,,109.44,percent of total billed charges,90% of total billed charges,48.48,136.8,
CARCINOEMBRYONIC ANTIGEN CEA,41009020,CDM,300,RC,82378,HCPCS,outpatient,,,108.75,65.25,,65.25,60,,52.2,percent of total billed charges,60% of total billed charges,52.2,48,,41.76,percent of total billed charges,48% of total billed charges,57.46,100,,,fee schedule,100% of bcbs custom fee schedule,57.46,100,,,fee schedule,100% of bcbs custom fee schedule,63.78,111,,,fee schedule,111% of bcbs custom fee schedule,54.38,50,,43.504,percent of total billed charges,50% of total billed charges,76.13,70,,60.904,percent of total billed charges,70% of total billed charges,52.72,48.48,,42.176,percent of total billed charges,48.48% of total billed charges,19.15,101,,,fee schedule,101% of cms custom fee schedule,52.72,48.48,,42.176,percent of total billed charges,48.48% of total billed charges,76.13,70,,60.904,percent of total billed charges,70% of total billed charges,76.13,70,,60.904,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,52.72,48.48,,42.176,percent of total billed charges,48.48% of total billed charges,97.88,90,,78.304,percent of total billed charges,90% of total billed charges,48.48,97.88,
"CALCITONIN, SERUM",,,300,RC,82308,HCPCS,outpatient,,,84,50.40,,50.4,60,,40.32,percent of total billed charges,60% of total billed charges,40.32,48,,32.256,percent of total billed charges,48% of total billed charges,81.09,100,,,fee schedule,100% of bcbs custom fee schedule,81.09,100,,,fee schedule,100% of bcbs custom fee schedule,90.01,111,,,fee schedule,111% of bcbs custom fee schedule,42,50,,33.6,percent of total billed charges,50% of total billed charges,58.8,70,,47.04,percent of total billed charges,70% of total billed charges,40.72,48.48,,32.576,percent of total billed charges,48.48% of total billed charges,27.06,101,,,fee schedule,101% of cms custom fee schedule,40.72,48.48,,32.576,percent of total billed charges,48.48% of total billed charges,58.8,70,,47.04,percent of total billed charges,70% of total billed charges,58.8,70,,47.04,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,40.72,48.48,,32.576,percent of total billed charges,48.48% of total billed charges,75.6,90,,60.48,percent of total billed charges,90% of total billed charges,40.72,90,
Proinsulin,,,300,RC,84206,HCPCS,outpatient,,,200,120.00,,120,60,,96,percent of total billed charges,60% of total billed charges,96,48,,76.8,percent of total billed charges,48% of total billed charges,53.95,100,,,fee schedule,100% of bcbs custom fee schedule,53.95,100,,,fee schedule,100% of bcbs custom fee schedule,59.88,111,,,fee schedule,111% of bcbs custom fee schedule,100,50,,80,percent of total billed charges,50% of total billed charges,140,70,,112,percent of total billed charges,70% of total billed charges,96.96,48.48,,77.568,percent of total billed charges,48.48% of total billed charges,26.96,101,,,fee schedule,101% of cms custom fee schedule,96.96,48.48,,77.568,percent of total billed charges,48.48% of total billed charges,140,70,,112,percent of total billed charges,70% of total billed charges,140,70,,112,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,96.96,48.48,,77.568,percent of total billed charges,48.48% of total billed charges,180,90,,144,percent of total billed charges,90% of total billed charges,48.48,180,
RBC Count,,,300,RC,85041,HCPCS,outpatient,,,25,15.00,,15,60,,12,percent of total billed charges,60% of total billed charges,12,48,,9.6,percent of total billed charges,48% of total billed charges,9.11,100,,,fee schedule,100% of bcbs custom fee schedule,9.11,100,,,fee schedule,100% of bcbs custom fee schedule,10.11,111,,,fee schedule,111% of bcbs custom fee schedule,12.5,50,,10,percent of total billed charges,50% of total billed charges,17.5,70,,14,percent of total billed charges,70% of total billed charges,12.12,48.48,,9.696,percent of total billed charges,48.48% of total billed charges,3.05,101,,,fee schedule,101% of cms custom fee schedule,12.12,48.48,,9.696,percent of total billed charges,48.48% of total billed charges,17.5,70,,14,percent of total billed charges,70% of total billed charges,17.5,70,,14,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,12.12,48.48,,9.696,percent of total billed charges,48.48% of total billed charges,22.5,90,,18,percent of total billed charges,90% of total billed charges,12.12,90,
Hemoglobin Fractionation,41000050,CDM,300,RC,83020,HCPCS,outpatient,,,35,21.00,,21,60,,16.8,percent of total billed charges,60% of total billed charges,16.8,48,,13.44,percent of total billed charges,48% of total billed charges,39,100,,,fee schedule,100% of bcbs custom fee schedule,39,100,,,fee schedule,100% of bcbs custom fee schedule,43.29,111,,,fee schedule,111% of bcbs custom fee schedule,17.5,50,,14,percent of total billed charges,50% of total billed charges,24.5,70,,19.6,percent of total billed charges,70% of total billed charges,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,13,101,,,fee schedule,101% of cms custom fee schedule,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,24.5,70,,19.6,percent of total billed charges,70% of total billed charges,24.5,70,,19.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,31.5,90,,25.2,percent of total billed charges,90% of total billed charges,16.97,90,
Methylmalonic Acid,41009106,CDM,300,RC,83921,HCPCS,outpatient,,,255,153.00,,153,60,,122.4,percent of total billed charges,60% of total billed charges,122.4,48,,97.92,percent of total billed charges,48% of total billed charges,49.86,100,,,fee schedule,100% of bcbs custom fee schedule,49.86,100,,,fee schedule,100% of bcbs custom fee schedule,55.34,111,,,fee schedule,111% of bcbs custom fee schedule,127.5,50,,102,percent of total billed charges,50% of total billed charges,178.5,70,,142.8,percent of total billed charges,70% of total billed charges,123.62,48.48,,98.896,percent of total billed charges,48.48% of total billed charges,21.42,101,,,fee schedule,101% of cms custom fee schedule,123.62,48.48,,98.896,percent of total billed charges,48.48% of total billed charges,178.5,70,,142.8,percent of total billed charges,70% of total billed charges,178.5,70,,142.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,123.62,48.48,,98.896,percent of total billed charges,48.48% of total billed charges,229.5,90,,183.6,percent of total billed charges,90% of total billed charges,48.48,229.5,
"Immunoassay Infectious Disease Antibody Quantitative, Each",41000076,CDM,300,RC,86317,HCPCS,outpatient,,,25,15.00,91,15,60,,12,percent of total billed charges,60% of total billed charges,12,48,,9.6,percent of total billed charges,48% of total billed charges,45.42,100,,,fee schedule,100% of bcbs custom fee schedule,45.42,100,,,fee schedule,100% of bcbs custom fee schedule,50.42,111,,,fee schedule,111% of bcbs custom fee schedule,12.5,50,,10,percent of total billed charges,50% of total billed charges,17.5,70,,14,percent of total billed charges,70% of total billed charges,12.12,48.48,,9.696,percent of total billed charges,48.48% of total billed charges,15.14,101,,,fee schedule,101% of cms custom fee schedule,12.12,48.48,,9.696,percent of total billed charges,48.48% of total billed charges,17.5,70,,14,percent of total billed charges,70% of total billed charges,17.5,70,,14,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,12.12,48.48,,9.696,percent of total billed charges,48.48% of total billed charges,22.5,90,,18,percent of total billed charges,90% of total billed charges,12.12,90,
Mycobacteria Culture,36000021,CDM,110,RC,87116,HCPCS,inpatient,,,105,63.00,91,790,100,,,per diem,pays based on per day rate,3650,100,,,per diem,pays based on per day rate,97.65,93,,78.12,percent of total billed charges,93% of total billed charges ,97.65,93,,78.12,percent of total billed charges,93% of total billed charges,97.65,93,,78.12,percent of total billed charges,93% of total billed charges,1025,100,,,per diem ,pays based on per day rate,73.5,70,,58.8,percent of total billed charges,70% of total billed charges,3650,100,,,per diem ,pays based on per day rate,3650,100,,,per diem ,pay based on per day rate,3650,100,,,per diem,pays based on per day rate,73.5,70,,58.8,percent of total billed charges,70% of total billed charges,73.5,70,,58.8,percent of total billed charges,70% of total billed charges,1400,100,,,per diem,pays based on per day rate,1400,100,,,per diem,pays based on per day rate,94.5,90,,75.6,percent of total billed charges,90% of total billed charges,90,1400,
Smear Fluorescent/Acid Stain,41000537,CDM,300,RC,87206,HCPCS,outpatient,,,25,15.00,91,15,60,,12,percent of total billed charges,60% of total billed charges,12,48,,9.6,percent of total billed charges,48% of total billed charges,16.26,100,,,fee schedule,100% of bcbs custom fee schedule,16.26,100,,,fee schedule,100% of bcbs custom fee schedule,18.05,111,,,fee schedule,111% of bcbs custom fee schedule,12.5,50,,10,percent of total billed charges,50% of total billed charges,17.5,70,,14,percent of total billed charges,70% of total billed charges,12.12,48.48,,9.696,percent of total billed charges,48.48% of total billed charges,5.44,101,,,fee schedule,101% of cms custom fee schedule,12.12,48.48,,9.696,percent of total billed charges,48.48% of total billed charges,17.5,70,,14,percent of total billed charges,70% of total billed charges,17.5,70,,14,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,12.12,48.48,,9.696,percent of total billed charges,48.48% of total billed charges,22.5,90,,18,percent of total billed charges,90% of total billed charges,12.12,90,
Infliximab,,,300,RC,80230,HCPCS,outpatient,,,300,180.00,,180,60,,144,percent of total billed charges,60% of total billed charges,144,48,,115.2,percent of total billed charges,48% of total billed charges,70.57,100,,,fee schedule,100% of bcbs custom fee schedule,70.57,100,,,fee schedule,100% of bcbs custom fee schedule,78.33,111,,,fee schedule,111% of bcbs custom fee schedule,150,50,,120,percent of total billed charges,50% of total billed charges,210,70,,168,percent of total billed charges,70% of total billed charges,145.44,48.48,,116.352,percent of total billed charges,48.48% of total billed charges,38.96,101,,,fee schedule,101% of cms custom fee schedule,145.44,48.48,,116.352,percent of total billed charges,48.48% of total billed charges,210,70,,168,percent of total billed charges,70% of total billed charges,210,70,,168,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,145.44,48.48,,116.352,percent of total billed charges,48.48% of total billed charges,270,90,,216,percent of total billed charges,90% of total billed charges,48.48,270,
Antibody to Infliximab,41000540,CDM,300,RC,83520,HCPCS,outpatient,,,230,138.00,,138,60,,110.4,percent of total billed charges,60% of total billed charges,110.4,48,,88.32,percent of total billed charges,48% of total billed charges,39.22,100,,,fee schedule,100% of bcbs custom fee schedule,39.22,100,,,fee schedule,100% of bcbs custom fee schedule,43.53,111,,,fee schedule,111% of bcbs custom fee schedule,115,50,,92,percent of total billed charges,50% of total billed charges,161,70,,128.8,percent of total billed charges,70% of total billed charges,111.5,48.48,,89.2,percent of total billed charges,48.48% of total billed charges,17.44,101,,,fee schedule,101% of cms custom fee schedule,111.5,48.48,,89.2,percent of total billed charges,48.48% of total billed charges,161,70,,128.8,percent of total billed charges,70% of total billed charges,161,70,,128.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,111.5,48.48,,89.2,percent of total billed charges,48.48% of total billed charges,207,90,,165.6,percent of total billed charges,90% of total billed charges,48.48,207,
"PETH - Phosphatidylethanol, Blood",,,300,RC,G0480,HCPCS,outpatient,,,202,121.20,91,121.2,60,,96.96,percent of total billed charges,60% of total billed charges,96.96,48,,77.568,percent of total billed charges,48% of total billed charges,146.27,100,,,fee schedule,100% of bcbs custom fee schedule,146.27,100,,,fee schedule,100% of bcbs custom fee schedule,162.36,111,,,fee schedule,111% of bcbs custom fee schedule,101,50,,80.8,percent of total billed charges,50% of total billed charges,141.4,70,,113.12,percent of total billed charges,70% of total billed charges,97.93,48.48,,78.344,percent of total billed charges,48.48% of total billed charges,115.57,101,,,fee schedule,101% of cms custom fee schedule,97.93,48.48,,78.344,percent of total billed charges,48.48% of total billed charges,141.4,70,,113.12,percent of total billed charges,70% of total billed charges,141.4,70,,113.12,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,97.93,48.48,,78.344,percent of total billed charges,48.48% of total billed charges,181.8,90,,145.44,percent of total billed charges,90% of total billed charges,48.48,181.8,
"Reducing Substances, Stool",41000467,CDM,300,RC,84376,HCPCS,outpatient,,,62,37.20,,37.2,60,,29.76,percent of total billed charges,60% of total billed charges,29.76,48,,23.808,percent of total billed charges,48% of total billed charges,16.66,100,,,fee schedule,100% of bcbs custom fee schedule,16.66,100,,,fee schedule,100% of bcbs custom fee schedule,18.49,111,,,fee schedule,111% of bcbs custom fee schedule,31,50,,24.8,percent of total billed charges,50% of total billed charges,43.4,70,,34.72,percent of total billed charges,70% of total billed charges,30.06,48.48,,24.048,percent of total billed charges,48.48% of total billed charges,5.56,101,,,fee schedule,101% of cms custom fee schedule,30.06,48.48,,24.048,percent of total billed charges,48.48% of total billed charges,43.4,70,,34.72,percent of total billed charges,70% of total billed charges,43.4,70,,34.72,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,30.06,48.48,,24.048,percent of total billed charges,48.48% of total billed charges,55.8,90,,44.64,percent of total billed charges,90% of total billed charges,30.06,90,
Entamoeba histolytica Antigen,,,300,RC,87337,HCPCS,outpatient,,,148,88.80,,88.8,60,,71.04,percent of total billed charges,60% of total billed charges,71.04,48,,56.832,percent of total billed charges,48% of total billed charges,36.33,100,,,fee schedule,100% of bcbs custom fee schedule,36.33,100,,,fee schedule,100% of bcbs custom fee schedule,40.33,111,,,fee schedule,111% of bcbs custom fee schedule,74,50,,59.2,percent of total billed charges,50% of total billed charges,103.6,70,,82.88,percent of total billed charges,70% of total billed charges,71.75,48.48,,57.4,percent of total billed charges,48.48% of total billed charges,12.1,101,,,fee schedule,101% of cms custom fee schedule,71.75,48.48,,57.4,percent of total billed charges,48.48% of total billed charges,103.6,70,,82.88,percent of total billed charges,70% of total billed charges,103.6,70,,82.88,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,71.75,48.48,,57.4,percent of total billed charges,48.48% of total billed charges,133.2,90,,106.56,percent of total billed charges,90% of total billed charges,48.48,133.2,
Herpes Simplex Virus Culture,,,300,RC,87255,HCPCS,outpatient,,,65,39.00,,39,60,,31.2,percent of total billed charges,60% of total billed charges,31.2,48,,24.96,percent of total billed charges,48% of total billed charges,102.56,100,,,fee schedule,100% of bcbs custom fee schedule,102.56,100,,,fee schedule,100% of bcbs custom fee schedule,113.84,111,,,fee schedule,111% of bcbs custom fee schedule,32.5,50,,26,percent of total billed charges,50% of total billed charges,45.5,70,,36.4,percent of total billed charges,70% of total billed charges,31.51,48.48,,25.208,percent of total billed charges,48.48% of total billed charges,34.2,101,,,fee schedule,101% of cms custom fee schedule,31.51,48.48,,25.208,percent of total billed charges,48.48% of total billed charges,45.5,70,,36.4,percent of total billed charges,70% of total billed charges,45.5,70,,36.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,31.51,48.48,,25.208,percent of total billed charges,48.48% of total billed charges,58.5,90,,46.8,percent of total billed charges,90% of total billed charges,31.51,90,
"Arsenic, blood",41000122,CDM,300,RC,82175,HCPCS,outpatient,,,75,45.00,,45,60,,36,percent of total billed charges,60% of total billed charges,36,48,,28.8,percent of total billed charges,48% of total billed charges,57.46,100,,,fee schedule,100% of bcbs custom fee schedule,57.46,100,,,fee schedule,100% of bcbs custom fee schedule,63.78,111,,,fee schedule,111% of bcbs custom fee schedule,37.5,50,,30,percent of total billed charges,50% of total billed charges,52.5,70,,42,percent of total billed charges,70% of total billed charges,36.36,48.48,,29.088,percent of total billed charges,48.48% of total billed charges,19.16,101,,,fee schedule,101% of cms custom fee schedule,36.36,48.48,,29.088,percent of total billed charges,48.48% of total billed charges,52.5,70,,42,percent of total billed charges,70% of total billed charges,52.5,70,,42,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,36.36,48.48,,29.088,percent of total billed charges,48.48% of total billed charges,67.5,90,,54,percent of total billed charges,90% of total billed charges,36.36,90,
"Mercury, blood",41000515,CDM,300,RC,83825,HCPCS,outpatient,,,73,43.80,,43.8,60,,35.04,percent of total billed charges,60% of total billed charges,35.04,48,,28.032,percent of total billed charges,48% of total billed charges,49.26,100,,,fee schedule,100% of bcbs custom fee schedule,49.26,100,,,fee schedule,100% of bcbs custom fee schedule,54.68,111,,,fee schedule,111% of bcbs custom fee schedule,36.5,50,,29.2,percent of total billed charges,50% of total billed charges,51.1,70,,40.88,percent of total billed charges,70% of total billed charges,35.39,48.48,,28.312,percent of total billed charges,48.48% of total billed charges,16.42,101,,,fee schedule,101% of cms custom fee schedule,35.39,48.48,,28.312,percent of total billed charges,48.48% of total billed charges,51.1,70,,40.88,percent of total billed charges,70% of total billed charges,51.1,70,,40.88,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,35.39,48.48,,28.312,percent of total billed charges,48.48% of total billed charges,65.7,90,,52.56,percent of total billed charges,90% of total billed charges,35.39,90,
Hep B DNA QUANT PCR,41001131,CDM,300,RC,87517,HCPCS,outpatient,,,315,189.00,,189,60,,151.2,percent of total billed charges,60% of total billed charges,151.2,48,,120.96,percent of total billed charges,48% of total billed charges,129.73,100,,,fee schedule,100% of bcbs custom fee schedule,129.73,100,,,fee schedule,100% of bcbs custom fee schedule,144,111,,,fee schedule,111% of bcbs custom fee schedule,157.5,50,,126,percent of total billed charges,50% of total billed charges,220.5,70,,176.4,percent of total billed charges,70% of total billed charges,152.71,48.48,,122.168,percent of total billed charges,48.48% of total billed charges,43.27,101,,,fee schedule,101% of cms custom fee schedule,152.71,48.48,,122.168,percent of total billed charges,48.48% of total billed charges,220.5,70,,176.4,percent of total billed charges,70% of total billed charges,220.5,70,,176.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,152.71,48.48,,122.168,percent of total billed charges,48.48% of total billed charges,283.5,90,,226.8,percent of total billed charges,90% of total billed charges,48.48,283.5,
Hepatitis Be Antigen,41000282,CDM,300,RC,87350,HCPCS,outpatient,,,54,32.40,,32.4,60,,25.92,percent of total billed charges,60% of total billed charges,25.92,48,,20.736,percent of total billed charges,48% of total billed charges,34.89,100,,,fee schedule,100% of bcbs custom fee schedule,34.89,100,,,fee schedule,100% of bcbs custom fee schedule,38.73,111,,,fee schedule,111% of bcbs custom fee schedule,27,50,,21.6,percent of total billed charges,50% of total billed charges,37.8,70,,30.24,percent of total billed charges,70% of total billed charges,26.18,48.48,,20.944,percent of total billed charges,48.48% of total billed charges,11.65,101,,,fee schedule,101% of cms custom fee schedule,26.18,48.48,,20.944,percent of total billed charges,48.48% of total billed charges,37.8,70,,30.24,percent of total billed charges,70% of total billed charges,37.8,70,,30.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,26.18,48.48,,20.944,percent of total billed charges,48.48% of total billed charges,48.6,90,,38.88,percent of total billed charges,90% of total billed charges,26.18,90,
"Glidin Antibody, each",,,300,RC,86258,HCPCS,outpatient,,,140,84.00,91,84,60,,67.2,percent of total billed charges,60% of total billed charges,67.2,48,,53.76,percent of total billed charges,48% of total billed charges,70,50,,56,percent of total billed charges,50% of total billed charges,70,50,,56,percent of total billed charges,50% of total billed charges,70,50,,56,percent of total billed charges,50% of total billed charges,70,50,,56,percent of total billed charges,50% of total billed charges,98,70,,78.4,percent of total billed charges,70% of total billed charges,67.87,48.48,,54.296,percent of total billed charges,48.48% of total billed charges,12.17,101,,,fee schedule,101% of cms custom fee schedule,67.87,48.48,,54.296,percent of total billed charges,48.48% of total billed charges,98,70,,78.4,percent of total billed charges,70% of total billed charges,98,70,,78.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,67.87,48.48,,54.296,percent of total billed charges,48.48% of total billed charges,126,90,,100.8,percent of total billed charges,90% of total billed charges,48.48,126,
"PSA, Free",41009112,CDM,300,RC,84154,HCPCS,outpatient,,,125.5,75.30,,75.3,60,,60.24,percent of total billed charges,60% of total billed charges,60.24,48,,48.192,percent of total billed charges,48% of total billed charges,55.71,100,,,fee schedule,100% of bcbs custom fee schedule,55.71,100,,,fee schedule,100% of bcbs custom fee schedule,61.84,111,,,fee schedule,111% of bcbs custom fee schedule,62.75,50,,50.2,percent of total billed charges,50% of total billed charges,87.85,70,,70.28,percent of total billed charges,70% of total billed charges,60.84,48.48,,48.672,percent of total billed charges,48.48% of total billed charges,18.57,101,,,fee schedule,101% of cms custom fee schedule,60.84,48.48,,48.672,percent of total billed charges,48.48% of total billed charges,87.85,70,,70.28,percent of total billed charges,70% of total billed charges,87.85,70,,70.28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,60.84,48.48,,48.672,percent of total billed charges,48.48% of total billed charges,112.95,90,,90.36,percent of total billed charges,90% of total billed charges,48.48,112.95,
Endomysial Antigody IgA,,,300,RC,86231,HCPCS,outpatient,,,150,90.00,91,90,60,,72,percent of total billed charges,60% of total billed charges,72,48,,57.6,percent of total billed charges,48% of total billed charges,75,50,,60,percent of total billed charges,50% of total billed charges,75,50,,60,percent of total billed charges,50% of total billed charges,75,50,,60,percent of total billed charges,50% of total billed charges,75,50,,60,percent of total billed charges,50% of total billed charges,105,70,,84,percent of total billed charges,70% of total billed charges,72.72,48.48,,58.176,percent of total billed charges,48.48% of total billed charges,12.21,101,,,fee schedule,101% of cms custom fee schedule,72.72,48.48,,58.176,percent of total billed charges,48.48% of total billed charges,105,70,,84,percent of total billed charges,70% of total billed charges,105,70,,84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,72.72,48.48,,58.176,percent of total billed charges,48.48% of total billed charges,135,90,,108,percent of total billed charges,90% of total billed charges,48.48,135,
"Parvovirus Antibody, each",41000806,CDM,300,RC,86747,HCPCS,outpatient,,,42,25.20,91,25.2,60,,20.16,percent of total billed charges,60% of total billed charges,20.16,48,,16.128,percent of total billed charges,48% of total billed charges,45.52,100,,,fee schedule,100% of bcbs custom fee schedule,45.52,100,,,fee schedule,100% of bcbs custom fee schedule,50.53,111,,,fee schedule,111% of bcbs custom fee schedule,21,50,,16.8,percent of total billed charges,50% of total billed charges,29.4,70,,23.52,percent of total billed charges,70% of total billed charges,20.36,48.48,,16.288,percent of total billed charges,48.48% of total billed charges,15.18,101,,,fee schedule,101% of cms custom fee schedule,20.36,48.48,,16.288,percent of total billed charges,48.48% of total billed charges,29.4,70,,23.52,percent of total billed charges,70% of total billed charges,29.4,70,,23.52,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,20.36,48.48,,16.288,percent of total billed charges,48.48% of total billed charges,37.8,90,,30.24,percent of total billed charges,90% of total billed charges,20.36,90,
BK VIRUS DNA PCR,41001159,CDM,300,RC,87799,HCPCS,outpatient,,,425,255.00,,255,60,,204,percent of total billed charges,60% of total billed charges,204,48,,163.2,percent of total billed charges,48% of total billed charges,129.73,100,,,fee schedule,100% of bcbs custom fee schedule,129.73,100,,,fee schedule,100% of bcbs custom fee schedule,144,111,,,fee schedule,111% of bcbs custom fee schedule,212.5,50,,170,percent of total billed charges,50% of total billed charges,297.5,70,,238,percent of total billed charges,70% of total billed charges,206.04,48.48,,164.832,percent of total billed charges,48.48% of total billed charges,43.27,101,,,fee schedule,101% of cms custom fee schedule,206.04,48.48,,164.832,percent of total billed charges,48.48% of total billed charges,297.5,70,,238,percent of total billed charges,70% of total billed charges,297.5,70,,238,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,206.04,48.48,,164.832,percent of total billed charges,48.48% of total billed charges,382.5,90,,306,percent of total billed charges,90% of total billed charges,48.48,382.5,
Cystatin-C,41001214,CDM,300,RC,82610,HCPCS,outpatient,,,216,129.60,,129.6,60,,103.68,percent of total billed charges,60% of total billed charges,103.68,48,,82.944,percent of total billed charges,48% of total billed charges,11.87,100,,,fee schedule,100% of bcbs custom fee schedule,11.87,100,,,fee schedule,100% of bcbs custom fee schedule,13.18,111,,,fee schedule,111% of bcbs custom fee schedule,108,50,,86.4,percent of total billed charges,50% of total billed charges,151.2,70,,120.96,percent of total billed charges,70% of total billed charges,104.72,48.48,,83.776,percent of total billed charges,48.48% of total billed charges,18.71,101,,,fee schedule,101% of cms custom fee schedule,104.72,48.48,,83.776,percent of total billed charges,48.48% of total billed charges,151.2,70,,120.96,percent of total billed charges,70% of total billed charges,151.2,70,,120.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,104.72,48.48,,83.776,percent of total billed charges,48.48% of total billed charges,194.4,90,,155.52,percent of total billed charges,90% of total billed charges,48.48,194.4,
ESTRONE,41001085,CDM,300,RC,82679,HCPCS,outpatient,,,187.5,112.50,,112.5,60,,90,percent of total billed charges,60% of total billed charges,90,48,,72,percent of total billed charges,48% of total billed charges,75.62,100,,,fee schedule,100% of bcbs custom fee schedule,75.62,100,,,fee schedule,100% of bcbs custom fee schedule,83.94,111,,,fee schedule,111% of bcbs custom fee schedule,93.75,50,,75,percent of total billed charges,50% of total billed charges,131.25,70,,105,percent of total billed charges,70% of total billed charges,90.9,48.48,,72.72,percent of total billed charges,48.48% of total billed charges,25.2,101,,,fee schedule,101% of cms custom fee schedule,90.9,48.48,,72.72,percent of total billed charges,48.48% of total billed charges,131.25,70,,105,percent of total billed charges,70% of total billed charges,131.25,70,,105,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,90.9,48.48,,72.72,percent of total billed charges,48.48% of total billed charges,168.75,90,,135,percent of total billed charges,90% of total billed charges,48.48,168.75,
DIHYDROTESTOSTERONE,,,300,RC,82642,HCPCS,outpatient,,,132.08,79.25,,79.25,60,,63.4,percent of total billed charges,60% of total billed charges,63.4,48,,50.72,percent of total billed charges,48% of total billed charges,59.52,100,,,fee schedule,100% of bcbs custom fee schedule,59.52,100,,,fee schedule,100% of bcbs custom fee schedule,66.07,111,,,fee schedule,111% of bcbs custom fee schedule,66.04,50,,52.832,percent of total billed charges,50% of total billed charges,92.46,70,,73.968,percent of total billed charges,70% of total billed charges,64.03,48.48,,51.224,percent of total billed charges,48.48% of total billed charges,29.57,101,,,fee schedule,101% of cms custom fee schedule,64.03,48.48,,51.224,percent of total billed charges,48.48% of total billed charges,92.46,70,,73.968,percent of total billed charges,70% of total billed charges,92.46,70,,73.968,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,64.03,48.48,,51.224,percent of total billed charges,48.48% of total billed charges,118.87,90,,95.096,percent of total billed charges,90% of total billed charges,48.48,118.87,
"Copper, Serum/Plasma",41000298,CDM,300,RC,82525,HCPCS,outpatient,,,160,96.00,91,96,60,,76.8,percent of total billed charges,60% of total billed charges,76.8,48,,61.44,percent of total billed charges,48% of total billed charges,37.59,100,,,fee schedule,100% of bcbs custom fee schedule,37.59,100,,,fee schedule,100% of bcbs custom fee schedule,41.72,111,,,fee schedule,111% of bcbs custom fee schedule,80,50,,64,percent of total billed charges,50% of total billed charges,112,70,,89.6,percent of total billed charges,70% of total billed charges,77.57,48.48,,62.056,percent of total billed charges,48.48% of total billed charges,12.53,101,,,fee schedule,101% of cms custom fee schedule,77.57,48.48,,62.056,percent of total billed charges,48.48% of total billed charges,112,70,,89.6,percent of total billed charges,70% of total billed charges,112,70,,89.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,77.57,48.48,,62.056,percent of total billed charges,48.48% of total billed charges,144,90,,115.2,percent of total billed charges,90% of total billed charges,48.48,144,
Prostatic Acid Phosphatase,41000025,CDM,300,RC,84066,HCPCS,outpatient,,,68,40.80,,40.8,60,,32.64,percent of total billed charges,60% of total billed charges,32.64,48,,26.112,percent of total billed charges,48% of total billed charges,29.26,100,,,fee schedule,100% of bcbs custom fee schedule,29.26,100,,,fee schedule,100% of bcbs custom fee schedule,32.48,111,,,fee schedule,111% of bcbs custom fee schedule,34,50,,27.2,percent of total billed charges,50% of total billed charges,47.6,70,,38.08,percent of total billed charges,70% of total billed charges,32.97,48.48,,26.376,percent of total billed charges,48.48% of total billed charges,9.76,101,,,fee schedule,101% of cms custom fee schedule,32.97,48.48,,26.376,percent of total billed charges,48.48% of total billed charges,47.6,70,,38.08,percent of total billed charges,70% of total billed charges,47.6,70,,38.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,32.97,48.48,,26.376,percent of total billed charges,48.48% of total billed charges,61.2,90,,48.96,percent of total billed charges,90% of total billed charges,32.97,90,
"COVID, Optical Rapid Antigen Test",,,300,RC,87811,HCPCS,outpatient,,,105,63.00,QW,63,60,,50.4,percent of total billed charges,60% of total billed charges,50.4,48,,40.32,percent of total billed charges,48% of total billed charges,41.38,100,,,fee schedule,100% of bcbs custom fee schedule,41.38,100,,,fee schedule,100% of bcbs custom fee schedule,45.93,111,,,fee schedule,111% of bcbs custom fee schedule,52.5,50,,42,percent of total billed charges,50% of total billed charges,73.5,70,,58.8,percent of total billed charges,70% of total billed charges,50.9,48.48,,40.72,percent of total billed charges,48.48% of total billed charges,41.79,101,,,fee schedule,101% of cms custom fee schedule,50.9,48.48,,40.72,percent of total billed charges,48.48% of total billed charges,73.5,70,,58.8,percent of total billed charges,70% of total billed charges,73.5,70,,58.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,50.9,48.48,,40.72,percent of total billed charges,48.48% of total billed charges,94.5,90,,75.6,percent of total billed charges,90% of total billed charges,48.48,94.5,
VITAMIN B12,41001002,CDM,300,RC,82607,HCPCS,outpatient,,,116.5,69.90,,69.9,60,,55.92,percent of total billed charges,60% of total billed charges,55.92,48,,44.736,percent of total billed charges,48% of total billed charges,45.66,100,,,fee schedule,100% of bcbs custom fee schedule,45.66,100,,,fee schedule,100% of bcbs custom fee schedule,50.68,111,,,fee schedule,111% of bcbs custom fee schedule,58.25,50,,46.6,percent of total billed charges,50% of total billed charges,81.55,70,,65.24,percent of total billed charges,70% of total billed charges,56.48,48.48,,45.184,percent of total billed charges,48.48% of total billed charges,15.23,101,,,fee schedule,101% of cms custom fee schedule,56.48,48.48,,45.184,percent of total billed charges,48.48% of total billed charges,81.55,70,,65.24,percent of total billed charges,70% of total billed charges,81.55,70,,65.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,56.48,48.48,,45.184,percent of total billed charges,48.48% of total billed charges,104.85,90,,83.88,percent of total billed charges,90% of total billed charges,48.48,104.85,
Calprotectin,,,300,RC,83993,HCPCS,outpatient,,,281.25,168.75,,168.75,60,,135,percent of total billed charges,60% of total billed charges,135,48,,108,percent of total billed charges,48% of total billed charges,50.16,100,,,fee schedule,100% of bcbs custom fee schedule,50.16,100,,,fee schedule,100% of bcbs custom fee schedule,55.68,111,,,fee schedule,111% of bcbs custom fee schedule,140.63,50,,112.504,percent of total billed charges,50% of total billed charges,196.88,70,,157.504,percent of total billed charges,70% of total billed charges,136.35,48.48,,109.08,percent of total billed charges,48.48% of total billed charges,19.83,101,,,fee schedule,101% of cms custom fee schedule,136.35,48.48,,109.08,percent of total billed charges,48.48% of total billed charges,196.88,70,,157.504,percent of total billed charges,70% of total billed charges,196.88,70,,157.504,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,136.35,48.48,,109.08,percent of total billed charges,48.48% of total billed charges,253.13,90,,202.504,percent of total billed charges,90% of total billed charges,48.48,253.13,
VIRUS INNOCULATION,,,300,RC,87254,HCPCS,outpatient,,,250,150.00,,150,60,,120,percent of total billed charges,60% of total billed charges,120,48,,96,percent of total billed charges,48% of total billed charges,59.22,100,,,fee schedule,100% of bcbs custom fee schedule,59.22,100,,,fee schedule,100% of bcbs custom fee schedule,65.73,111,,,fee schedule,111% of bcbs custom fee schedule,125,50,,100,percent of total billed charges,50% of total billed charges,175,70,,140,percent of total billed charges,70% of total billed charges,121.2,48.48,,96.96,percent of total billed charges,48.48% of total billed charges,19.76,101,,,fee schedule,101% of cms custom fee schedule,121.2,48.48,,96.96,percent of total billed charges,48.48% of total billed charges,175,70,,140,percent of total billed charges,70% of total billed charges,175,70,,140,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,121.2,48.48,,96.96,percent of total billed charges,48.48% of total billed charges,225,90,,180,percent of total billed charges,90% of total billed charges,48.48,225,
Alpha Fetoprotein,41000604,CDM,300,RC,82105,HCPCS,outpatient,,,108.75,65.25,,65.25,60,,52.2,percent of total billed charges,60% of total billed charges,52.2,48,,41.76,percent of total billed charges,48% of total billed charges,50.81,100,,,fee schedule,100% of bcbs custom fee schedule,50.81,100,,,fee schedule,100% of bcbs custom fee schedule,56.4,111,,,fee schedule,111% of bcbs custom fee schedule,54.38,50,,43.504,percent of total billed charges,50% of total billed charges,76.13,70,,60.904,percent of total billed charges,70% of total billed charges,52.72,48.48,,42.176,percent of total billed charges,48.48% of total billed charges,16.94,101,,,fee schedule,101% of cms custom fee schedule,52.72,48.48,,42.176,percent of total billed charges,48.48% of total billed charges,76.13,70,,60.904,percent of total billed charges,70% of total billed charges,76.13,70,,60.904,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,52.72,48.48,,42.176,percent of total billed charges,48.48% of total billed charges,97.88,90,,78.304,percent of total billed charges,90% of total billed charges,48.48,97.88,
FIBROSURE NASH,,,300,RC,81599,HCPCS,outpatient,,,288.75,173.25,,173.25,60,,138.6,percent of total billed charges,60% of total billed charges,138.6,48,,110.88,percent of total billed charges,48% of total billed charges,144.38,50,,115.504,percent of total billed charges,50% of total billed charges,144.38,50,,115.504,percent of total billed charges,50% of total billed charges,144.38,50,,115.504,percent of total billed charges,50% of total billed charges,144.38,50,,115.504,percent of total billed charges,50% of total billed charges,202.13,70,,161.704,percent of total billed charges,70% of total billed charges,139.99,48.48,,111.992,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,139.99,48.48,,111.992,percent of total billed charges,48.48% of total billed charges,202.13,70,,161.704,percent of total billed charges,70% of total billed charges,202.13,70,,161.704,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,139.99,48.48,,111.992,percent of total billed charges,48.48% of total billed charges,259.88,90,,207.904,percent of total billed charges,90% of total billed charges,48.48,259.88,
"SCR C/V CYTO, THINLAYER, RESCR, MEDIARE",,,300,RC,,,outpatient,,,66.4,39.84,,39.84,60,,31.872,percent of total billed charges,60% of total billed charges,31.87,48,,25.496,percent of total billed charges,48% of total billed charges,33.2,50,,26.56,percent of total billed charges,50% of total billed charges,33.2,50,,26.56,percent of total billed charges,50% of total billed charges,33.2,50,,26.56,percent of total billed charges,50% of total billed charges,33.2,50,,26.56,percent of total billed charges,50% of total billed charges,46.48,70,,37.184,percent of total billed charges,70% of total billed charges,32.19,48.48,,25.752,percent of total billed charges,48.48% of total billed charges,32.19,48.48,,25.752,percent of total billed charges,48.48% of total billed charges,32.19,48.48,,25.752,percent of total billed charges,48.48% of total billed charges,46.48,70,,37.184,percent of total billed charges,70% of total billed charges,46.48,70,,37.184,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,32.19,48.48,,25.752,percent of total billed charges,48.48% of total billed charges,59.76,90,,47.808,percent of total billed charges,90% of total billed charges,32.19,90,
BMP W IONIZED CALCIUM,,,300,RC,80047,HCPCS,outpatient,,,113.75,68.25,QW,68.25,60,,54.6,percent of total billed charges,60% of total billed charges,54.6,48,,43.68,percent of total billed charges,48% of total billed charges,55.83,100,,,fee schedule,100% of bcbs custom fee schedule,55.83,100,,,fee schedule,100% of bcbs custom fee schedule,61.97,111,,,fee schedule,111% of bcbs custom fee schedule,56.88,50,,45.504,percent of total billed charges,50% of total billed charges,79.63,70,,63.704,percent of total billed charges,70% of total billed charges,55.15,48.48,,44.12,percent of total billed charges,48.48% of total billed charges,13.87,101,,,fee schedule,101% of cms custom fee schedule,55.15,48.48,,44.12,percent of total billed charges,48.48% of total billed charges,79.63,70,,63.704,percent of total billed charges,70% of total billed charges,79.63,70,,63.704,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,55.15,48.48,,44.12,percent of total billed charges,48.48% of total billed charges,102.38,90,,81.904,percent of total billed charges,90% of total billed charges,48.48,102.38,
NH Port Access for Blood Collection,32000103,CDM,300,RC,36591,HCPCS,outpatient,,,23.58,14.15,,14.15,60,,11.32,percent of total billed charges,60% of total billed charges,11.32,48,,9.056,percent of total billed charges,48% of total billed charges,138.08,100,,,fee schedule,100% of bcbs custom fee schedule,138.08,100,,,fee schedule,100% of bcbs custom fee schedule,153.27,111,,,fee schedule,111% of bcbs custom fee schedule,11.79,50,,9.432,percent of total billed charges,50% of total billed charges,16.51,70,,13.208,percent of total billed charges,70% of total billed charges,11.43,48.48,,9.144,percent of total billed charges,48.48% of total billed charges,27.39,116.15,,,fee schedule,116.51% of cms physician fee schedule,11.43,48.48,,9.144,percent of total billed charges,48.48% of total billed charges,16.51,70,,13.208,percent of total billed charges,70% of total billed charges,16.51,70,,13.208,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,11.43,48.48,,9.144,percent of total billed charges,48.48% of total billed charges,21.22,90,,16.976,percent of total billed charges,90% of total billed charges,11.43,90,
FRESH FROZEN PLAZMA,,,390,RC,P9059,HCPCS,outpatient,,,313.75,188.25,,188.25,60,,150.6,percent of total billed charges,60% of total billed charges,150.6,48,,120.48,percent of total billed charges,48% of total billed charges,156.88,50,,125.504,percent of total billed charges,50% of total billed charges,156.88,50,,125.504,percent of total billed charges,50% of total billed charges,156.88,50,,125.504,percent of total billed charges,50% of total billed charges,156.88,50,,125.504,percent of total billed charges,50% of total billed charges,219.63,70,,175.704,percent of total billed charges,70% of total billed charges,152.11,48.48,,121.688,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,152.11,48.48,,121.688,percent of total billed charges,48.48% of total billed charges,219.63,70,,175.704,percent of total billed charges,70% of total billed charges,219.63,70,,175.704,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,152.11,48.48,,121.688,percent of total billed charges,48.48% of total billed charges,282.38,90,,225.904,percent of total billed charges,90% of total billed charges,48.48,282.38,
PLATELET PHERESIS 6/8 UN,,,390,RC,P9053,HCPCS,outpatient,,,1391.25,834.75,,834.75,60,,667.8,percent of total billed charges,60% of total billed charges,667.8,48,,534.24,percent of total billed charges,48% of total billed charges,695.63,50,,556.504,percent of total billed charges,50% of total billed charges,695.63,50,,556.504,percent of total billed charges,50% of total billed charges,695.63,50,,556.504,percent of total billed charges,50% of total billed charges,695.63,50,,556.504,percent of total billed charges,50% of total billed charges,973.88,70,,779.104,percent of total billed charges,70% of total billed charges,674.48,48.48,,539.584,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,674.48,48.48,,539.584,percent of total billed charges,48.48% of total billed charges,973.88,70,,779.104,percent of total billed charges,70% of total billed charges,973.88,70,,779.104,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,674.48,48.48,,539.584,percent of total billed charges,48.48% of total billed charges,1252.13,90,,1001.704,percent of total billed charges,90% of total billed charges,48.48,1252.13,
LEUKO RBC,41040204,CDM,381,RC,P9016,HCPCS,outpatient,,,478.75,287.25,BL,287.25,60,,229.8,percent of total billed charges,60% of total billed charges,229.8,48,,183.84,percent of total billed charges,48% of total billed charges,245.88,100,,,fee schedule,100% of bcbs custom fee schedule,245.88,100,,,fee schedule,100% of bcbs custom fee schedule,272.93,111,,,fee schedule,111% of bcbs custom fee schedule,239.38,50,,191.504,percent of total billed charges,50% of total billed charges,335.13,70,,268.104,percent of total billed charges,70% of total billed charges,232.1,48.48,,185.68,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,232.1,48.48,,185.68,percent of total billed charges,48.48% of total billed charges,335.13,70,,268.104,percent of total billed charges,70% of total billed charges,335.13,70,,268.104,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,232.1,48.48,,185.68,percent of total billed charges,48.48% of total billed charges,430.88,90,,344.704,percent of total billed charges,90% of total billed charges,48.48,430.88,
EKG,43102076,CDM,730,RC,93005,HCPCS,outpatient,,,93.75,56.25,,56.25,60,,45,percent of total billed charges,60% of total billed charges,45,48,,36,percent of total billed charges,48% of total billed charges,49.35,100,,,fee schedule,100% of bcbs custom fee schedule,49.35,100,,,fee schedule,100% of bcbs custom fee schedule,54.78,111,,,fee schedule,111% of bcbs custom fee schedule,46.88,50,,37.504,percent of total billed charges,50% of total billed charges,65.63,70,,52.504,percent of total billed charges,70% of total billed charges,45.45,48.48,,36.36,percent of total billed charges,48.48% of total billed charges,6.53,116.15,,,fee schedule,116.51% of cms physician fee schedule,45.45,48.48,,36.36,percent of total billed charges,48.48% of total billed charges,65.63,70,,52.504,percent of total billed charges,70% of total billed charges,65.63,70,,52.504,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,45.45,48.48,,36.36,percent of total billed charges,48.48% of total billed charges,84.38,90,,67.504,percent of total billed charges,90% of total billed charges,45.45,90,
T-SPINE 3 VIEWS,42000785,CDM,320,RC,72072,HCPCS,outpatient,,,450,270.00,TC,270,60,,216,percent of total billed charges,60% of total billed charges,216,48,,172.8,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,225,50,,180,percent of total billed charges,50% of total billed charges,315,70,,252,percent of total billed charges,70% of total billed charges,218.16,48.48,,174.528,percent of total billed charges,48.48% of total billed charges,41.6,116.15,,,fee schedule,116.51% of cms physician fee schedule,218.16,48.48,,174.528,percent of total billed charges,48.48% of total billed charges,315,70,,252,percent of total billed charges,70% of total billed charges,315,70,,252,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,218.16,48.48,,174.528,percent of total billed charges,48.48% of total billed charges,405,90,,324,percent of total billed charges,90% of total billed charges,48.48,405,
SPIROMETRY PRE/POST TRTMT,43102037,CDM,460,RC,94060,HCPCS,outpatient,,,437.5,262.50,,262.5,60,,210,percent of total billed charges,60% of total billed charges,210,48,,168,percent of total billed charges,48% of total billed charges,125.28,100,,,fee schedule,100% of bcbs custom fee schedule,125.28,100,,,fee schedule,100% of bcbs custom fee schedule,139.06,111,,,fee schedule,111% of bcbs custom fee schedule,218.75,50,,175,percent of total billed charges,50% of total billed charges,306.25,70,,245,percent of total billed charges,70% of total billed charges,212.1,48.48,,169.68,percent of total billed charges,48.48% of total billed charges,40.88,116.15,,,fee schedule,116.51% of cms physician fee schedule,212.1,48.48,,169.68,percent of total billed charges,48.48% of total billed charges,306.25,70,,245,percent of total billed charges,70% of total billed charges,306.25,70,,245,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,212.1,48.48,,169.68,percent of total billed charges,48.48% of total billed charges,393.75,90,,315,percent of total billed charges,90% of total billed charges,48.48,393.75,
MANDIBLE MIN 4 VIEWS RT,42000490,CDM,320,RC,70110,HCPCS,outpatient,,,440,264.00,TC,264,60,,211.2,percent of total billed charges,60% of total billed charges,211.2,48,,168.96,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,220,50,,176,percent of total billed charges,50% of total billed charges,308,70,,246.4,percent of total billed charges,70% of total billed charges,213.31,48.48,,170.648,percent of total billed charges,48.48% of total billed charges,45.76,116.15,,,fee schedule,116.51% of cms physician fee schedule,213.31,48.48,,170.648,percent of total billed charges,48.48% of total billed charges,308,70,,246.4,percent of total billed charges,70% of total billed charges,308,70,,246.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,213.31,48.48,,170.648,percent of total billed charges,48.48% of total billed charges,396,90,,316.8,percent of total billed charges,90% of total billed charges,48.48,396,
MANDIBLE LESS THAN 4 VIEWS,,,320,RC,70100,HCPCS,outpatient,,,378,226.80,TC,226.8,60,,181.44,percent of total billed charges,60% of total billed charges,181.44,48,,145.152,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,189,50,,151.2,percent of total billed charges,50% of total billed charges,264.6,70,,211.68,percent of total billed charges,70% of total billed charges,183.25,48.48,,146.6,percent of total billed charges,48.48% of total billed charges,40.69,116.15,,,fee schedule,116.51% of cms physician fee schedule,183.25,48.48,,146.6,percent of total billed charges,48.48% of total billed charges,264.6,70,,211.68,percent of total billed charges,70% of total billed charges,264.6,70,,211.68,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,183.25,48.48,,146.6,percent of total billed charges,48.48% of total billed charges,340.2,90,,272.16,percent of total billed charges,90% of total billed charges,48.48,340.2,
MASTOID 3 VIEWS,42000495,CDM,320,RC,70130,HCPCS,outpatient,,,378,226.80,TC,226.8,60,,181.44,percent of total billed charges,60% of total billed charges,181.44,48,,145.152,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,189,50,,151.2,percent of total billed charges,50% of total billed charges,264.6,70,,211.68,percent of total billed charges,70% of total billed charges,183.25,48.48,,146.6,percent of total billed charges,48.48% of total billed charges,64.93,116.15,,,fee schedule,116.51% of cms physician fee schedule,183.25,48.48,,146.6,percent of total billed charges,48.48% of total billed charges,264.6,70,,211.68,percent of total billed charges,70% of total billed charges,264.6,70,,211.68,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,183.25,48.48,,146.6,percent of total billed charges,48.48% of total billed charges,340.2,90,,272.16,percent of total billed charges,90% of total billed charges,48.48,340.2,
FACIAL BONES LESS THAN 3 VIEWS,,,320,RC,70140,HCPCS,outpatient,,,378,226.80,TC,226.8,60,,181.44,percent of total billed charges,60% of total billed charges,181.44,48,,145.152,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,189,50,,151.2,percent of total billed charges,50% of total billed charges,264.6,70,,211.68,percent of total billed charges,70% of total billed charges,183.25,48.48,,146.6,percent of total billed charges,48.48% of total billed charges,33.63,116.15,,,fee schedule,116.51% of cms physician fee schedule,183.25,48.48,,146.6,percent of total billed charges,48.48% of total billed charges,264.6,70,,211.68,percent of total billed charges,70% of total billed charges,264.6,70,,211.68,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,183.25,48.48,,146.6,percent of total billed charges,48.48% of total billed charges,340.2,90,,272.16,percent of total billed charges,90% of total billed charges,48.48,340.2,
FACIAL BONES 3 VIEWS,42000295,CDM,320,RC,70150,HCPCS,outpatient,,,481,288.60,TC,288.6,60,,230.88,percent of total billed charges,60% of total billed charges,230.88,48,,184.704,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,240.5,50,,192.4,percent of total billed charges,50% of total billed charges,336.7,70,,269.36,percent of total billed charges,70% of total billed charges,233.19,48.48,,186.552,percent of total billed charges,48.48% of total billed charges,49.54,116.15,,,fee schedule,116.51% of cms physician fee schedule,233.19,48.48,,186.552,percent of total billed charges,48.48% of total billed charges,336.7,70,,269.36,percent of total billed charges,70% of total billed charges,336.7,70,,269.36,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,233.19,48.48,,186.552,percent of total billed charges,48.48% of total billed charges,432.9,90,,346.32,percent of total billed charges,90% of total billed charges,48.48,432.9,
NASAL BONES 3 VIEWS,42000555,CDM,320,RC,70160,HCPCS,outpatient,,,378,226.80,TC,226.8,60,,181.44,percent of total billed charges,60% of total billed charges,181.44,48,,145.152,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,189,50,,151.2,percent of total billed charges,50% of total billed charges,264.6,70,,211.68,percent of total billed charges,70% of total billed charges,183.25,48.48,,146.6,percent of total billed charges,48.48% of total billed charges,39.29,116.15,,,fee schedule,116.51% of cms physician fee schedule,183.25,48.48,,146.6,percent of total billed charges,48.48% of total billed charges,264.6,70,,211.68,percent of total billed charges,70% of total billed charges,264.6,70,,211.68,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,183.25,48.48,,146.6,percent of total billed charges,48.48% of total billed charges,340.2,90,,272.16,percent of total billed charges,90% of total billed charges,48.48,340.2,
ORBIT 4 VIEWS,42000605,CDM,320,RC,70200,HCPCS,outpatient,,,490,294.00,TC,294,60,,235.2,percent of total billed charges,60% of total billed charges,235.2,48,,188.16,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,245,50,,196,percent of total billed charges,50% of total billed charges,343,70,,274.4,percent of total billed charges,70% of total billed charges,237.55,48.48,,190.04,percent of total billed charges,48.48% of total billed charges,50.32,116.15,,,fee schedule,116.51% of cms physician fee schedule,237.55,48.48,,190.04,percent of total billed charges,48.48% of total billed charges,343,70,,274.4,percent of total billed charges,70% of total billed charges,343,70,,274.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,237.55,48.48,,190.04,percent of total billed charges,48.48% of total billed charges,441,90,,352.8,percent of total billed charges,90% of total billed charges,48.48,441,
SINUSES LESS THAN 3 VIEWS,,,320,RC,70210,HCPCS,outpatient,,,147.5,88.50,TC,88.5,60,,70.8,percent of total billed charges,60% of total billed charges,70.8,48,,56.64,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,73.75,50,,59,percent of total billed charges,50% of total billed charges,103.25,70,,82.6,percent of total billed charges,70% of total billed charges,71.51,48.48,,57.208,percent of total billed charges,48.48% of total billed charges,33.87,116.15,,,fee schedule,116.51% of cms physician fee schedule,71.51,48.48,,57.208,percent of total billed charges,48.48% of total billed charges,103.25,70,,82.6,percent of total billed charges,70% of total billed charges,103.25,70,,82.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,71.51,48.48,,57.208,percent of total billed charges,48.48% of total billed charges,132.75,90,,106.2,percent of total billed charges,90% of total billed charges,48.48,132.75,
SINUSES MIN 3 VIEWS,42000730,CDM,320,RC,70220,HCPCS,outpatient,,,436,261.60,TC,43,100,,,fee schedule,100% of aetna fee schedule,209.28,48,,167.424,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,218,50,,174.4,percent of total billed charges,50% of total billed charges,305.2,70,,244.16,percent of total billed charges,70% of total billed charges,211.37,48.48,,169.096,percent of total billed charges,48.48% of total billed charges,39.53,116.15,,,fee schedule,116.51% of cms physician fee schedule,211.37,48.48,,169.096,percent of total billed charges,48.48% of total billed charges,305.2,70,,244.16,percent of total billed charges,70% of total billed charges,305.2,70,,244.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,211.37,48.48,,169.096,percent of total billed charges,48.48% of total billed charges,392.4,90,,313.92,percent of total billed charges,90% of total billed charges,48.48,392.4,
SKULL SERIES < 4 VIEWS,42000740,CDM,320,RC,70250,HCPCS,outpatient,,,419,251.40,TC,251.4,60,,201.12,percent of total billed charges,60% of total billed charges,201.12,48,,160.896,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,209.5,50,,167.6,percent of total billed charges,50% of total billed charges,293.3,70,,234.64,percent of total billed charges,70% of total billed charges,203.13,48.48,,162.504,percent of total billed charges,48.48% of total billed charges,37.64,116.15,,,fee schedule,116.51% of cms physician fee schedule,203.13,48.48,,162.504,percent of total billed charges,48.48% of total billed charges,293.3,70,,234.64,percent of total billed charges,70% of total billed charges,293.3,70,,234.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,203.13,48.48,,162.504,percent of total billed charges,48.48% of total billed charges,377.1,90,,301.68,percent of total billed charges,90% of total billed charges,48.48,377.1,
SKULL SERIES 4 VIEWS MIN,42000745,CDM,320,RC,70260,HCPCS,outpatient,,,531,318.60,TC,318.6,60,,254.88,percent of total billed charges,60% of total billed charges,254.88,48,,203.904,percent of total billed charges,48% of total billed charges,109.7,100,,,fee schedule,100% of bcbs custom fee schedule,109.7,100,,,fee schedule,100% of bcbs custom fee schedule,121.77,111,,,fee schedule,111% of bcbs custom fee schedule,265.5,50,,212.4,percent of total billed charges,50% of total billed charges,371.7,70,,297.36,percent of total billed charges,70% of total billed charges,257.43,48.48,,205.944,percent of total billed charges,48.48% of total billed charges,46.92,116.15,,,fee schedule,116.51% of cms physician fee schedule,257.43,48.48,,205.944,percent of total billed charges,48.48% of total billed charges,371.7,70,,297.36,percent of total billed charges,70% of total billed charges,371.7,70,,297.36,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,257.43,48.48,,205.944,percent of total billed charges,48.48% of total billed charges,477.9,90,,382.32,percent of total billed charges,90% of total billed charges,48.48,477.9,
TMJ LEFT,,,320,RC,70328,HCPCS,outpatient,,,357,214.20,TC,214.2,60,,171.36,percent of total billed charges,60% of total billed charges,171.36,48,,137.088,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,178.5,50,,142.8,percent of total billed charges,50% of total billed charges,249.9,70,,199.92,percent of total billed charges,70% of total billed charges,173.07,48.48,,138.456,percent of total billed charges,48.48% of total billed charges,36.29,116.15,,,fee schedule,116.51% of cms physician fee schedule,173.07,48.48,,138.456,percent of total billed charges,48.48% of total billed charges,249.9,70,,199.92,percent of total billed charges,70% of total billed charges,249.9,70,,199.92,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,173.07,48.48,,138.456,percent of total billed charges,48.48% of total billed charges,321.3,90,,257.04,percent of total billed charges,90% of total billed charges,48.48,321.3,
TMJ RIGHT,,,320,RC,70328,HCPCS,outpatient,,,357,214.20,TC,214.2,60,,171.36,percent of total billed charges,60% of total billed charges,171.36,48,,137.088,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,178.5,50,,142.8,percent of total billed charges,50% of total billed charges,249.9,70,,199.92,percent of total billed charges,70% of total billed charges,173.07,48.48,,138.456,percent of total billed charges,48.48% of total billed charges,36.29,116.15,,,fee schedule,116.51% of cms physician fee schedule,173.07,48.48,,138.456,percent of total billed charges,48.48% of total billed charges,249.9,70,,199.92,percent of total billed charges,70% of total billed charges,249.9,70,,199.92,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,173.07,48.48,,138.456,percent of total billed charges,48.48% of total billed charges,321.3,90,,257.04,percent of total billed charges,90% of total billed charges,48.48,321.3,
TMJ BILATERAL,42000805,CDM,320,RC,70330,HCPCS,outpatient,,,535,321.00,TC,321,60,,256.8,percent of total billed charges,60% of total billed charges,256.8,48,,205.44,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,267.5,50,,214,percent of total billed charges,50% of total billed charges,374.5,70,,299.6,percent of total billed charges,70% of total billed charges,259.37,48.48,,207.496,percent of total billed charges,48.48% of total billed charges,55.21,116.15,,,fee schedule,116.51% of cms physician fee schedule,259.37,48.48,,207.496,percent of total billed charges,48.48% of total billed charges,374.5,70,,299.6,percent of total billed charges,70% of total billed charges,374.5,70,,299.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,259.37,48.48,,207.496,percent of total billed charges,48.48% of total billed charges,481.5,90,,385.2,percent of total billed charges,90% of total billed charges,48.48,481.5,
NECK SOFT TISSUE,42000560,CDM,320,RC,70360,HCPCS,outpatient,,,328,196.80,TC,196.8,60,,157.44,percent of total billed charges,60% of total billed charges,157.44,48,,125.952,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,164,50,,131.2,percent of total billed charges,50% of total billed charges,229.6,70,,183.68,percent of total billed charges,70% of total billed charges,159.01,48.48,,127.208,percent of total billed charges,48.48% of total billed charges,32.91,116.15,,,fee schedule,116.51% of cms physician fee schedule,159.01,48.48,,127.208,percent of total billed charges,48.48% of total billed charges,229.6,70,,183.68,percent of total billed charges,70% of total billed charges,229.6,70,,183.68,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,159.01,48.48,,127.208,percent of total billed charges,48.48% of total billed charges,295.2,90,,236.16,percent of total billed charges,90% of total billed charges,48.48,295.2,
CHEST 1 VIEW,42000165,CDM,324,RC,71045,HCPCS,outpatient,,,261,156.60,TC,156.6,60,,125.28,percent of total billed charges,60% of total billed charges,125.28,48,,100.224,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,130.5,50,,104.4,percent of total billed charges,50% of total billed charges,182.7,70,,146.16,percent of total billed charges,70% of total billed charges,126.53,48.48,,101.224,percent of total billed charges,48.48% of total billed charges,27.14,116.15,,,fee schedule,116.51% of cms physician fee schedule,126.53,48.48,,101.224,percent of total billed charges,48.48% of total billed charges,182.7,70,,146.16,percent of total billed charges,70% of total billed charges,182.7,70,,146.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,126.53,48.48,,101.224,percent of total billed charges,48.48% of total billed charges,234.9,90,,187.92,percent of total billed charges,90% of total billed charges,48.48,234.9,
CHEST 2 VIEWS PA/LAT,42000170,CDM,324,RC,71046,HCPCS,outpatient,,,324,194.40,TC,194.4,60,,155.52,percent of total billed charges,60% of total billed charges,155.52,48,,124.416,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,162,50,,129.6,percent of total billed charges,50% of total billed charges,226.8,70,,181.44,percent of total billed charges,70% of total billed charges,157.08,48.48,,125.664,percent of total billed charges,48.48% of total billed charges,35.46,116.15,,,fee schedule,116.51% of cms physician fee schedule,157.08,48.48,,125.664,percent of total billed charges,48.48% of total billed charges,226.8,70,,181.44,percent of total billed charges,70% of total billed charges,226.8,70,,181.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,157.08,48.48,,125.664,percent of total billed charges,48.48% of total billed charges,291.6,90,,233.28,percent of total billed charges,90% of total billed charges,48.48,291.6,
CHEST LAT DECUB,42000172,CDM,324,RC,71048,HCPCS,outpatient,,,382,229.20,,229.2,60,,183.36,percent of total billed charges,60% of total billed charges,183.36,48,,146.688,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,191,50,,152.8,percent of total billed charges,50% of total billed charges,267.4,70,,213.92,percent of total billed charges,70% of total billed charges,185.19,48.48,,148.152,percent of total billed charges,48.48% of total billed charges,48.09,116.15,,,fee schedule,116.51% of cms physician fee schedule,185.19,48.48,,148.152,percent of total billed charges,48.48% of total billed charges,267.4,70,,213.92,percent of total billed charges,70% of total billed charges,267.4,70,,213.92,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,185.19,48.48,,148.152,percent of total billed charges,48.48% of total billed charges,343.8,90,,275.04,percent of total billed charges,90% of total billed charges,48.48,343.8,
RIBS UNILAT 2 VIEWS LT,42000676,CDM,320,RC,71100,HCPCS,outpatient,,,382,229.20,TC,229.2,60,,183.36,percent of total billed charges,60% of total billed charges,183.36,48,,146.688,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,191,50,,152.8,percent of total billed charges,50% of total billed charges,267.4,70,,213.92,percent of total billed charges,70% of total billed charges,185.19,48.48,,148.152,percent of total billed charges,48.48% of total billed charges,38.52,116.15,,,fee schedule,116.51% of cms physician fee schedule,185.19,48.48,,148.152,percent of total billed charges,48.48% of total billed charges,267.4,70,,213.92,percent of total billed charges,70% of total billed charges,267.4,70,,213.92,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,185.19,48.48,,148.152,percent of total billed charges,48.48% of total billed charges,343.8,90,,275.04,percent of total billed charges,90% of total billed charges,48.48,343.8,
RIBS BILATERAL 3 VIEWS,42000670,CDM,320,RC,71110,HCPCS,outpatient,,,573,343.80,TC,343.8,60,,275.04,percent of total billed charges,60% of total billed charges,275.04,48,,220.032,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,286.5,50,,229.2,percent of total billed charges,50% of total billed charges,401.1,70,,320.88,percent of total billed charges,70% of total billed charges,277.79,48.48,,222.232,percent of total billed charges,48.48% of total billed charges,46.3,116.15,,,fee schedule,116.51% of cms physician fee schedule,277.79,48.48,,222.232,percent of total billed charges,48.48% of total billed charges,401.1,70,,320.88,percent of total billed charges,70% of total billed charges,401.1,70,,320.88,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,277.79,48.48,,222.232,percent of total billed charges,48.48% of total billed charges,515.7,90,,412.56,percent of total billed charges,90% of total billed charges,48.48,515.7,
RIBS BILAT 4V W/ PA CHEST,42000685,CDM,320,RC,71111,HCPCS,outpatient,,,252.5,151.50,TC,151.5,60,,121.2,percent of total billed charges,60% of total billed charges,121.2,48,,96.96,percent of total billed charges,48% of total billed charges,109.7,100,,,fee schedule,100% of bcbs custom fee schedule,109.7,100,,,fee schedule,100% of bcbs custom fee schedule,121.77,111,,,fee schedule,111% of bcbs custom fee schedule,126.25,50,,101,percent of total billed charges,50% of total billed charges,176.75,70,,141.4,percent of total billed charges,70% of total billed charges,122.41,48.48,,97.928,percent of total billed charges,48.48% of total billed charges,55.36,116.15,,,fee schedule,116.51% of cms physician fee schedule,122.41,48.48,,97.928,percent of total billed charges,48.48% of total billed charges,176.75,70,,141.4,percent of total billed charges,70% of total billed charges,176.75,70,,141.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,122.41,48.48,,97.928,percent of total billed charges,48.48% of total billed charges,227.25,90,,181.8,percent of total billed charges,90% of total billed charges,48.48,227.25,
SCAPULA BILATERAL,42000701,CDM,320,RC,73010,HCPCS,outpatient,,,523,313.80,TC,313.8,60,,251.04,percent of total billed charges,60% of total billed charges,251.04,48,,200.832,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,261.5,50,,209.2,percent of total billed charges,50% of total billed charges,366.1,70,,292.88,percent of total billed charges,70% of total billed charges,253.55,48.48,,202.84,percent of total billed charges,48.48% of total billed charges,25.4,116.15,,,fee schedule,116.51% of cms physician fee schedule,253.55,48.48,,202.84,percent of total billed charges,48.48% of total billed charges,366.1,70,,292.88,percent of total billed charges,70% of total billed charges,366.1,70,,292.88,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,253.55,48.48,,202.84,percent of total billed charges,48.48% of total billed charges,470.7,90,,376.56,percent of total billed charges,90% of total billed charges,48.48,470.7,
STERNUM 2 VIEWS,42000775,CDM,320,RC,71120,HCPCS,outpatient,,,344,206.40,TC,206.4,60,,165.12,percent of total billed charges,60% of total billed charges,165.12,48,,132.096,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,172,50,,137.6,percent of total billed charges,50% of total billed charges,240.8,70,,192.64,percent of total billed charges,70% of total billed charges,166.77,48.48,,133.416,percent of total billed charges,48.48% of total billed charges,35.37,116.15,,,fee schedule,116.51% of cms physician fee schedule,166.77,48.48,,133.416,percent of total billed charges,48.48% of total billed charges,240.8,70,,192.64,percent of total billed charges,70% of total billed charges,240.8,70,,192.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,166.77,48.48,,133.416,percent of total billed charges,48.48% of total billed charges,309.6,90,,247.68,percent of total billed charges,90% of total billed charges,48.48,309.6,
SPINE SINGLE VIEW,42000765,CDM,320,RC,72020,HCPCS,outpatient,,,128.75,77.25,TC,77.25,60,,61.8,percent of total billed charges,60% of total billed charges,61.8,48,,49.44,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,64.38,50,,51.504,percent of total billed charges,50% of total billed charges,90.13,70,,72.104,percent of total billed charges,70% of total billed charges,62.42,48.48,,49.936,percent of total billed charges,48.48% of total billed charges,25.69,116.15,,,fee schedule,116.51% of cms physician fee schedule,62.42,48.48,,49.936,percent of total billed charges,48.48% of total billed charges,90.13,70,,72.104,percent of total billed charges,70% of total billed charges,90.13,70,,72.104,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,62.42,48.48,,49.936,percent of total billed charges,48.48% of total billed charges,115.88,90,,92.704,percent of total billed charges,90% of total billed charges,48.48,115.88,
C-SPINE 2-3 VIEWS,42000240,CDM,320,RC,72040,HCPCS,outpatient,,,386,231.60,TC,231.6,60,,185.28,percent of total billed charges,60% of total billed charges,185.28,48,,148.224,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,193,50,,154.4,percent of total billed charges,50% of total billed charges,270.2,70,,216.16,percent of total billed charges,70% of total billed charges,187.13,48.48,,149.704,percent of total billed charges,48.48% of total billed charges,41.56,116.15,,,fee schedule,116.51% of cms physician fee schedule,187.13,48.48,,149.704,percent of total billed charges,48.48% of total billed charges,270.2,70,,216.16,percent of total billed charges,70% of total billed charges,270.2,70,,216.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,187.13,48.48,,149.704,percent of total billed charges,48.48% of total billed charges,347.4,90,,277.92,percent of total billed charges,90% of total billed charges,48.48,347.4,
HAND BILATERAL 3VIEW,42000361,CDM,320,RC,73130,HCPCS,outpatient,,,535,321.00,TC,29,100,,,fee schedule,100% of aetna fee schedule,256.8,48,,205.44,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,267.5,50,,214,percent of total billed charges,50% of total billed charges,374.5,70,,299.6,percent of total billed charges,70% of total billed charges,259.37,48.48,,207.496,percent of total billed charges,48.48% of total billed charges,38.95,116.15,,,fee schedule,116.51% of cms physician fee schedule,259.37,48.48,,207.496,percent of total billed charges,48.48% of total billed charges,374.5,70,,299.6,percent of total billed charges,70% of total billed charges,374.5,70,,299.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,259.37,48.48,,207.496,percent of total billed charges,48.48% of total billed charges,481.5,90,,385.2,percent of total billed charges,90% of total billed charges,48.48,481.5,
C-SPINE MIN 4-5 VIEWS,42000235,CDM,320,RC,72050,HCPCS,outpatient,,,523,313.80,TC,313.8,60,,251.04,percent of total billed charges,60% of total billed charges,251.04,48,,200.832,percent of total billed charges,48% of total billed charges,109.7,100,,,fee schedule,100% of bcbs custom fee schedule,109.7,100,,,fee schedule,100% of bcbs custom fee schedule,121.77,111,,,fee schedule,111% of bcbs custom fee schedule,261.5,50,,209.2,percent of total billed charges,50% of total billed charges,366.1,70,,292.88,percent of total billed charges,70% of total billed charges,253.55,48.48,,202.84,percent of total billed charges,48.48% of total billed charges,56.03,116.15,,,fee schedule,116.51% of cms physician fee schedule,253.55,48.48,,202.84,percent of total billed charges,48.48% of total billed charges,366.1,70,,292.88,percent of total billed charges,70% of total billed charges,366.1,70,,292.88,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,253.55,48.48,,202.84,percent of total billed charges,48.48% of total billed charges,470.7,90,,376.56,percent of total billed charges,90% of total billed charges,48.48,470.7,
C-SPINE 6 VW flex/exten,42000230,CDM,320,RC,72052,HCPCS,outpatient,,,656,393.60,TC,393.6,60,,314.88,percent of total billed charges,60% of total billed charges,314.88,48,,251.904,percent of total billed charges,48% of total billed charges,109.7,100,,,fee schedule,100% of bcbs custom fee schedule,109.7,100,,,fee schedule,100% of bcbs custom fee schedule,121.77,111,,,fee schedule,111% of bcbs custom fee schedule,328,50,,262.4,percent of total billed charges,50% of total billed charges,459.2,70,,367.36,percent of total billed charges,70% of total billed charges,318.03,48.48,,254.424,percent of total billed charges,48.48% of total billed charges,65.42,116.15,,,fee schedule,116.51% of cms physician fee schedule,318.03,48.48,,254.424,percent of total billed charges,48.48% of total billed charges,459.2,70,,367.36,percent of total billed charges,70% of total billed charges,459.2,70,,367.36,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,318.03,48.48,,254.424,percent of total billed charges,48.48% of total billed charges,590.4,90,,472.32,percent of total billed charges,90% of total billed charges,48.48,590.4,
T-SPINE 2 VIEWS,42000790,CDM,320,RC,72070,HCPCS,outpatient,,,394,236.40,TC,236.4,60,,189.12,percent of total billed charges,60% of total billed charges,189.12,48,,151.296,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,197,50,,157.6,percent of total billed charges,50% of total billed charges,275.8,70,,220.64,percent of total billed charges,70% of total billed charges,191.01,48.48,,152.808,percent of total billed charges,48.48% of total billed charges,34.69,116.15,,,fee schedule,116.51% of cms physician fee schedule,191.01,48.48,,152.808,percent of total billed charges,48.48% of total billed charges,275.8,70,,220.64,percent of total billed charges,70% of total billed charges,275.8,70,,220.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,191.01,48.48,,152.808,percent of total billed charges,48.48% of total billed charges,354.6,90,,283.68,percent of total billed charges,90% of total billed charges,48.48,354.6,
LS-SPINE 2-3 VIEWS,42000455,CDM,320,RC,72100,HCPCS,outpatient,,,407,244.20,TC,244.2,60,,195.36,percent of total billed charges,60% of total billed charges,195.36,48,,156.288,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,203.5,50,,162.8,percent of total billed charges,50% of total billed charges,284.9,70,,227.92,percent of total billed charges,70% of total billed charges,197.31,48.48,,157.848,percent of total billed charges,48.48% of total billed charges,41.9,116.15,,,fee schedule,116.51% of cms physician fee schedule,197.31,48.48,,157.848,percent of total billed charges,48.48% of total billed charges,284.9,70,,227.92,percent of total billed charges,70% of total billed charges,284.9,70,,227.92,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,197.31,48.48,,157.848,percent of total billed charges,48.48% of total billed charges,366.3,90,,293.04,percent of total billed charges,90% of total billed charges,48.48,366.3,
LS-SPINE MIN 4 VIEWS,42000465,CDM,320,RC,72110,HCPCS,outpatient,,,569,341.40,TC,50,100,,,fee schedule,100% of aetna fee schedule,273.12,48,,218.496,percent of total billed charges,48% of total billed charges,109.7,100,,,fee schedule,100% of bcbs custom fee schedule,109.7,100,,,fee schedule,100% of bcbs custom fee schedule,121.77,111,,,fee schedule,111% of bcbs custom fee schedule,284.5,50,,227.6,percent of total billed charges,50% of total billed charges,398.3,70,,318.64,percent of total billed charges,70% of total billed charges,275.85,48.48,,220.68,percent of total billed charges,48.48% of total billed charges,54.29,116.15,,,fee schedule,116.51% of cms physician fee schedule,275.85,48.48,,220.68,percent of total billed charges,48.48% of total billed charges,398.3,70,,318.64,percent of total billed charges,70% of total billed charges,398.3,70,,318.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,275.85,48.48,,220.68,percent of total billed charges,48.48% of total billed charges,512.1,90,,409.68,percent of total billed charges,90% of total billed charges,48.48,512.1,
L-SPINE FLEX/EXT/BENDING,42000460,CDM,320,RC,72120,HCPCS,outpatient,,,469,281.40,TC,281.4,60,,225.12,percent of total billed charges,60% of total billed charges,225.12,48,,180.096,percent of total billed charges,48% of total billed charges,109.7,100,,,fee schedule,100% of bcbs custom fee schedule,109.7,100,,,fee schedule,100% of bcbs custom fee schedule,121.77,111,,,fee schedule,111% of bcbs custom fee schedule,234.5,50,,187.6,percent of total billed charges,50% of total billed charges,328.3,70,,262.64,percent of total billed charges,70% of total billed charges,227.37,48.48,,181.896,percent of total billed charges,48.48% of total billed charges,42.58,116.15,,,fee schedule,116.51% of cms physician fee schedule,227.37,48.48,,181.896,percent of total billed charges,48.48% of total billed charges,328.3,70,,262.64,percent of total billed charges,70% of total billed charges,328.3,70,,262.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,227.37,48.48,,181.896,percent of total billed charges,48.48% of total billed charges,422.1,90,,337.68,percent of total billed charges,90% of total billed charges,48.48,422.1,
PELVIS AP VIEW,42000635,CDM,320,RC,72170,HCPCS,outpatient,,,369,221.40,TC,221.4,60,,177.12,percent of total billed charges,60% of total billed charges,177.12,48,,141.696,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,184.5,50,,147.6,percent of total billed charges,50% of total billed charges,258.3,70,,206.64,percent of total billed charges,70% of total billed charges,178.89,48.48,,143.112,percent of total billed charges,48.48% of total billed charges,29.47,116.15,,,fee schedule,116.51% of cms physician fee schedule,178.89,48.48,,143.112,percent of total billed charges,48.48% of total billed charges,258.3,70,,206.64,percent of total billed charges,70% of total billed charges,258.3,70,,206.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,178.89,48.48,,143.112,percent of total billed charges,48.48% of total billed charges,332.1,90,,265.68,percent of total billed charges,90% of total billed charges,48.48,332.1,
PELVIS MIN 3 VIEWS,42000630,CDM,320,RC,72190,HCPCS,outpatient,,,444,266.40,TC,266.4,60,,213.12,percent of total billed charges,60% of total billed charges,213.12,48,,170.496,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,222,50,,177.6,percent of total billed charges,50% of total billed charges,310.8,70,,248.64,percent of total billed charges,70% of total billed charges,215.25,48.48,,172.2,percent of total billed charges,48.48% of total billed charges,44.42,116.15,,,fee schedule,116.51% of cms physician fee schedule,215.25,48.48,,172.2,percent of total billed charges,48.48% of total billed charges,310.8,70,,248.64,percent of total billed charges,70% of total billed charges,310.8,70,,248.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,215.25,48.48,,172.2,percent of total billed charges,48.48% of total billed charges,399.6,90,,319.68,percent of total billed charges,90% of total billed charges,48.48,399.6,
SACRUM/COCCYX MIN 2VIEW,42000695,CDM,320,RC,72220,HCPCS,outpatient,,,328,196.80,TC,196.8,60,,157.44,percent of total billed charges,60% of total billed charges,157.44,48,,125.952,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,164,50,,131.2,percent of total billed charges,50% of total billed charges,229.6,70,,183.68,percent of total billed charges,70% of total billed charges,159.01,48.48,,127.208,percent of total billed charges,48.48% of total billed charges,34.21,116.15,,,fee schedule,116.51% of cms physician fee schedule,159.01,48.48,,127.208,percent of total billed charges,48.48% of total billed charges,229.6,70,,183.68,percent of total billed charges,70% of total billed charges,229.6,70,,183.68,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,159.01,48.48,,127.208,percent of total billed charges,48.48% of total billed charges,295.2,90,,236.16,percent of total billed charges,90% of total billed charges,48.48,295.2,
CLAVICLE 2 VIEW LT,42000206,CDM,320,RC,73000,HCPCS,outpatient,,,320,192.00,TC,192,60,,153.6,percent of total billed charges,60% of total billed charges,153.6,48,,122.88,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,160,50,,128,percent of total billed charges,50% of total billed charges,224,70,,179.2,percent of total billed charges,70% of total billed charges,155.14,48.48,,124.112,percent of total billed charges,48.48% of total billed charges,34.16,116.15,,,fee schedule,116.51% of cms physician fee schedule,155.14,48.48,,124.112,percent of total billed charges,48.48% of total billed charges,224,70,,179.2,percent of total billed charges,70% of total billed charges,224,70,,179.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,155.14,48.48,,124.112,percent of total billed charges,48.48% of total billed charges,288,90,,230.4,percent of total billed charges,90% of total billed charges,48.48,288,
SHOULDER BILATERAL,42000716,CDM,320,RC,73030,HCPCS,outpatient,,,398,238.80,TC,31,100,,,fee schedule,100% of aetna fee schedule,191.04,48,,152.832,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,199,50,,159.2,percent of total billed charges,50% of total billed charges,278.6,70,,222.88,percent of total billed charges,70% of total billed charges,192.95,48.48,,154.36,percent of total billed charges,48.48% of total billed charges,36.62,116.15,,,fee schedule,116.51% of cms physician fee schedule,192.95,48.48,,154.36,percent of total billed charges,48.48% of total billed charges,278.6,70,,222.88,percent of total billed charges,70% of total billed charges,278.6,70,,222.88,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,192.95,48.48,,154.36,percent of total billed charges,48.48% of total billed charges,358.2,90,,286.56,percent of total billed charges,90% of total billed charges,48.48,358.2,
SHOULDER MIN 2 VIEWS,42000716,CDM,320,RC,73030,HCPCS,outpatient,,,336,201.60,TC,31,100,,,fee schedule,100% of aetna fee schedule,161.28,48,,129.024,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,168,50,,134.4,percent of total billed charges,50% of total billed charges,235.2,70,,188.16,percent of total billed charges,70% of total billed charges,162.89,48.48,,130.312,percent of total billed charges,48.48% of total billed charges,36.62,116.15,,,fee schedule,116.51% of cms physician fee schedule,162.89,48.48,,130.312,percent of total billed charges,48.48% of total billed charges,235.2,70,,188.16,percent of total billed charges,70% of total billed charges,235.2,70,,188.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,162.89,48.48,,130.312,percent of total billed charges,48.48% of total billed charges,302.4,90,,241.92,percent of total billed charges,90% of total billed charges,48.48,302.4,
AC JTS W/WO WTS,42000005,CDM,320,RC,73050,HCPCS,outpatient,,,415,249.00,TC,249,60,,199.2,percent of total billed charges,60% of total billed charges,199.2,48,,159.36,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,207.5,50,,166,percent of total billed charges,50% of total billed charges,290.5,70,,232.4,percent of total billed charges,70% of total billed charges,201.19,48.48,,160.952,percent of total billed charges,48.48% of total billed charges,30.54,116.15,,,fee schedule,116.51% of cms physician fee schedule,201.19,48.48,,160.952,percent of total billed charges,48.48% of total billed charges,290.5,70,,232.4,percent of total billed charges,70% of total billed charges,290.5,70,,232.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,201.19,48.48,,160.952,percent of total billed charges,48.48% of total billed charges,373.5,90,,298.8,percent of total billed charges,90% of total billed charges,48.48,373.5,
HUMERUS MIN 2 VIEWS,42000381,CDM,320,RC,73060,HCPCS,outpatient,,,336,201.60,TC,201.6,60,,161.28,percent of total billed charges,60% of total billed charges,161.28,48,,129.024,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,168,50,,134.4,percent of total billed charges,50% of total billed charges,235.2,70,,188.16,percent of total billed charges,70% of total billed charges,162.89,48.48,,130.312,percent of total billed charges,48.48% of total billed charges,33.49,116.15,,,fee schedule,116.51% of cms physician fee schedule,162.89,48.48,,130.312,percent of total billed charges,48.48% of total billed charges,235.2,70,,188.16,percent of total billed charges,70% of total billed charges,235.2,70,,188.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,162.89,48.48,,130.312,percent of total billed charges,48.48% of total billed charges,302.4,90,,241.92,percent of total billed charges,90% of total billed charges,48.48,302.4,
ELBOW 2 VIEWS LT,42000266,CDM,320,RC,73070,HCPCS,outpatient,,,320,192.00,TC,192,60,,153.6,percent of total billed charges,60% of total billed charges,153.6,48,,122.88,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,160,50,,128,percent of total billed charges,50% of total billed charges,224,70,,179.2,percent of total billed charges,70% of total billed charges,155.14,48.48,,124.112,percent of total billed charges,48.48% of total billed charges,30.77,116.15,,,fee schedule,116.51% of cms physician fee schedule,155.14,48.48,,124.112,percent of total billed charges,48.48% of total billed charges,224,70,,179.2,percent of total billed charges,70% of total billed charges,224,70,,179.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,155.14,48.48,,124.112,percent of total billed charges,48.48% of total billed charges,288,90,,230.4,percent of total billed charges,90% of total billed charges,48.48,288,
ELBOW COMP 3 VW LT,42000271,CDM,320,RC,73080,HCPCS,outpatient,,,361,216.60,TC,216.6,60,,173.28,percent of total billed charges,60% of total billed charges,173.28,48,,138.624,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,180.5,50,,144.4,percent of total billed charges,50% of total billed charges,252.7,70,,202.16,percent of total billed charges,70% of total billed charges,175.01,48.48,,140.008,percent of total billed charges,48.48% of total billed charges,34.54,116.15,,,fee schedule,116.51% of cms physician fee schedule,175.01,48.48,,140.008,percent of total billed charges,48.48% of total billed charges,252.7,70,,202.16,percent of total billed charges,70% of total billed charges,252.7,70,,202.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,175.01,48.48,,140.008,percent of total billed charges,48.48% of total billed charges,324.9,90,,259.92,percent of total billed charges,90% of total billed charges,48.48,324.9,
FOREARM 2 VIEWS LT,42000346,CDM,320,RC,73090,HCPCS,outpatient,,,299,179.40,TC,179.4,60,,143.52,percent of total billed charges,60% of total billed charges,143.52,48,,114.816,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,149.5,50,,119.6,percent of total billed charges,50% of total billed charges,209.3,70,,167.44,percent of total billed charges,70% of total billed charges,144.96,48.48,,115.968,percent of total billed charges,48.48% of total billed charges,30.77,116.15,,,fee schedule,116.51% of cms physician fee schedule,144.96,48.48,,115.968,percent of total billed charges,48.48% of total billed charges,209.3,70,,167.44,percent of total billed charges,70% of total billed charges,209.3,70,,167.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,144.96,48.48,,115.968,percent of total billed charges,48.48% of total billed charges,269.1,90,,215.28,percent of total billed charges,90% of total billed charges,48.48,269.1,
UPPER EXT(INFANT) 2 VW,42000851,CDM,320,RC,73092,HCPCS,outpatient,,,315,189.00,TC,189,60,,151.2,percent of total billed charges,60% of total billed charges,151.2,48,,120.96,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,157.5,50,,126,percent of total billed charges,50% of total billed charges,220.5,70,,176.4,percent of total billed charges,70% of total billed charges,152.71,48.48,,122.168,percent of total billed charges,48.48% of total billed charges,33.15,116.15,,,fee schedule,116.51% of cms physician fee schedule,152.71,48.48,,122.168,percent of total billed charges,48.48% of total billed charges,220.5,70,,176.4,percent of total billed charges,70% of total billed charges,220.5,70,,176.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,152.71,48.48,,122.168,percent of total billed charges,48.48% of total billed charges,283.5,90,,226.8,percent of total billed charges,90% of total billed charges,48.48,283.5,
WRIST 2 VIEWS,42000886,CDM,320,RC,73100,HCPCS,outpatient,,,340,204.00,TC,204,60,,163.2,percent of total billed charges,60% of total billed charges,163.2,48,,130.56,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,170,50,,136,percent of total billed charges,50% of total billed charges,238,70,,190.4,percent of total billed charges,70% of total billed charges,164.83,48.48,,131.864,percent of total billed charges,48.48% of total billed charges,35.52,116.15,,,fee schedule,116.51% of cms physician fee schedule,164.83,48.48,,131.864,percent of total billed charges,48.48% of total billed charges,238,70,,190.4,percent of total billed charges,70% of total billed charges,238,70,,190.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,164.83,48.48,,131.864,percent of total billed charges,48.48% of total billed charges,306,90,,244.8,percent of total billed charges,90% of total billed charges,48.48,306,
SCAPULA RT,42000701,CDM,320,RC,73010,HCPCS,outpatient,,,349,209.40,TC,209.4,60,,167.52,percent of total billed charges,60% of total billed charges,167.52,48,,134.016,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,174.5,50,,139.6,percent of total billed charges,50% of total billed charges,244.3,70,,195.44,percent of total billed charges,70% of total billed charges,169.2,48.48,,135.36,percent of total billed charges,48.48% of total billed charges,25.4,116.15,,,fee schedule,116.51% of cms physician fee schedule,169.2,48.48,,135.36,percent of total billed charges,48.48% of total billed charges,244.3,70,,195.44,percent of total billed charges,70% of total billed charges,244.3,70,,195.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,169.2,48.48,,135.36,percent of total billed charges,48.48% of total billed charges,314.1,90,,251.28,percent of total billed charges,90% of total billed charges,48.48,314.1,
WRIST 3 VIEWS LT,42000892,CDM,320,RC,73110,HCPCS,outpatient,,,411,246.60,TC,29,100,,,fee schedule,100% of aetna fee schedule,197.28,48,,157.824,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,205.5,50,,164.4,percent of total billed charges,50% of total billed charges,287.7,70,,230.16,percent of total billed charges,70% of total billed charges,199.25,48.48,,159.4,percent of total billed charges,48.48% of total billed charges,43.01,116.15,,,fee schedule,116.51% of cms physician fee schedule,199.25,48.48,,159.4,percent of total billed charges,48.48% of total billed charges,287.7,70,,230.16,percent of total billed charges,70% of total billed charges,287.7,70,,230.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,199.25,48.48,,159.4,percent of total billed charges,48.48% of total billed charges,369.9,90,,295.92,percent of total billed charges,90% of total billed charges,48.48,369.9,
SCAPULA LT,42000701,CDM,320,RC,73010,HCPCS,outpatient,,,349,209.40,TC,209.4,60,,167.52,percent of total billed charges,60% of total billed charges,167.52,48,,134.016,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,174.5,50,,139.6,percent of total billed charges,50% of total billed charges,244.3,70,,195.44,percent of total billed charges,70% of total billed charges,169.2,48.48,,135.36,percent of total billed charges,48.48% of total billed charges,25.4,116.15,,,fee schedule,116.51% of cms physician fee schedule,169.2,48.48,,135.36,percent of total billed charges,48.48% of total billed charges,244.3,70,,195.44,percent of total billed charges,70% of total billed charges,244.3,70,,195.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,169.2,48.48,,135.36,percent of total billed charges,48.48% of total billed charges,314.1,90,,251.28,percent of total billed charges,90% of total billed charges,48.48,314.1,
HAND 2 VIEWS LT,42000356,CDM,320,RC,73120,HCPCS,outpatient,,,303,181.80,TC,181.8,60,,145.44,percent of total billed charges,60% of total billed charges,145.44,48,,116.352,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,151.5,50,,121.2,percent of total billed charges,50% of total billed charges,212.1,70,,169.68,percent of total billed charges,70% of total billed charges,146.89,48.48,,117.512,percent of total billed charges,48.48% of total billed charges,33.15,116.15,,,fee schedule,116.51% of cms physician fee schedule,146.89,48.48,,117.512,percent of total billed charges,48.48% of total billed charges,212.1,70,,169.68,percent of total billed charges,70% of total billed charges,212.1,70,,169.68,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,146.89,48.48,,117.512,percent of total billed charges,48.48% of total billed charges,272.7,90,,218.16,percent of total billed charges,90% of total billed charges,48.48,272.7,
WRIST BILATERAL,42000892,CDM,320,RC,73110,HCPCS,outpatient,,,510,306.00,TC,29,100,,,fee schedule,100% of aetna fee schedule,244.8,48,,195.84,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,255,50,,204,percent of total billed charges,50% of total billed charges,357,70,,285.6,percent of total billed charges,70% of total billed charges,247.25,48.48,,197.8,percent of total billed charges,48.48% of total billed charges,43.01,116.15,,,fee schedule,116.51% of cms physician fee schedule,247.25,48.48,,197.8,percent of total billed charges,48.48% of total billed charges,357,70,,285.6,percent of total billed charges,70% of total billed charges,357,70,,285.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,247.25,48.48,,197.8,percent of total billed charges,48.48% of total billed charges,459,90,,367.2,percent of total billed charges,90% of total billed charges,48.48,459,
HAND 3 VIEWS LT,42000361,CDM,320,RC,73130,HCPCS,outpatient,,,357,214.20,TC,29,100,,,fee schedule,100% of aetna fee schedule,171.36,48,,137.088,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,178.5,50,,142.8,percent of total billed charges,50% of total billed charges,249.9,70,,199.92,percent of total billed charges,70% of total billed charges,173.07,48.48,,138.456,percent of total billed charges,48.48% of total billed charges,38.95,116.15,,,fee schedule,116.51% of cms physician fee schedule,173.07,48.48,,138.456,percent of total billed charges,48.48% of total billed charges,249.9,70,,199.92,percent of total billed charges,70% of total billed charges,249.9,70,,199.92,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,173.07,48.48,,138.456,percent of total billed charges,48.48% of total billed charges,321.3,90,,257.04,percent of total billed charges,90% of total billed charges,48.48,321.3,
FINGER 2 VIEW LT,42000910,CDM,320,RC,73140,HCPCS,outpatient,,,365,219.00,TC,219,60,,175.2,percent of total billed charges,60% of total billed charges,175.2,48,,140.16,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,182.5,50,,146,percent of total billed charges,50% of total billed charges,255.5,70,,204.4,percent of total billed charges,70% of total billed charges,176.95,48.48,,141.56,percent of total billed charges,48.48% of total billed charges,39.77,116.15,,,fee schedule,116.51% of cms physician fee schedule,176.95,48.48,,141.56,percent of total billed charges,48.48% of total billed charges,255.5,70,,204.4,percent of total billed charges,70% of total billed charges,255.5,70,,204.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,176.95,48.48,,141.56,percent of total billed charges,48.48% of total billed charges,328.5,90,,262.8,percent of total billed charges,90% of total billed charges,48.48,328.5,
HIP UNILAT 1 VW LT,42001063,CDM,320,RC,73501,HCPCS,outpatient,,,349,209.40,TC,209.4,60,,167.52,percent of total billed charges,60% of total billed charges,167.52,48,,134.016,percent of total billed charges,48% of total billed charges,32.68,100,,,fee schedule,100% of bcbs custom fee schedule,32.68,100,,,fee schedule,100% of bcbs custom fee schedule,36.27,111,,,fee schedule,111% of bcbs custom fee schedule,174.5,50,,139.6,percent of total billed charges,50% of total billed charges,244.3,70,,195.44,percent of total billed charges,70% of total billed charges,169.2,48.48,,135.36,percent of total billed charges,48.48% of total billed charges,34.59,116.15,,,fee schedule,116.51% of cms physician fee schedule,169.2,48.48,,135.36,percent of total billed charges,48.48% of total billed charges,244.3,70,,195.44,percent of total billed charges,70% of total billed charges,244.3,70,,195.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,169.2,48.48,,135.36,percent of total billed charges,48.48% of total billed charges,314.1,90,,251.28,percent of total billed charges,90% of total billed charges,48.48,314.1,
HIP UNILAT 2 VW LT,42001065,CDM,320,RC,73502,HCPCS,outpatient,,,481,288.60,TC,288.6,60,,230.88,percent of total billed charges,60% of total billed charges,230.88,48,,184.704,percent of total billed charges,48% of total billed charges,48.17,100,,,fee schedule,100% of bcbs custom fee schedule,48.17,100,,,fee schedule,100% of bcbs custom fee schedule,53.47,111,,,fee schedule,111% of bcbs custom fee schedule,240.5,50,,192.4,percent of total billed charges,50% of total billed charges,336.7,70,,269.36,percent of total billed charges,70% of total billed charges,233.19,48.48,,186.552,percent of total billed charges,48.48% of total billed charges,49.69,116.15,,,fee schedule,116.51% of cms physician fee schedule,233.19,48.48,,186.552,percent of total billed charges,48.48% of total billed charges,336.7,70,,269.36,percent of total billed charges,70% of total billed charges,336.7,70,,269.36,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,233.19,48.48,,186.552,percent of total billed charges,48.48% of total billed charges,432.9,90,,346.32,percent of total billed charges,90% of total billed charges,48.48,432.9,
HIP BILAT W/ AP PELVIS 2v,42001069,CDM,320,RC,73521,HCPCS,outpatient,,,722,433.20,TC,433.2,60,,346.56,percent of total billed charges,60% of total billed charges,346.56,48,,277.248,percent of total billed charges,48% of total billed charges,45.31,100,,,fee schedule,100% of bcbs custom fee schedule,45.31,100,,,fee schedule,100% of bcbs custom fee schedule,50.29,111,,,fee schedule,111% of bcbs custom fee schedule,361,50,,288.8,percent of total billed charges,50% of total billed charges,505.4,70,,404.32,percent of total billed charges,70% of total billed charges,350.03,48.48,,280.024,percent of total billed charges,48.48% of total billed charges,43.25,116.15,,,fee schedule,116.51% of cms physician fee schedule,350.03,48.48,,280.024,percent of total billed charges,48.48% of total billed charges,505.4,70,,404.32,percent of total billed charges,70% of total billed charges,505.4,70,,404.32,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,350.03,48.48,,280.024,percent of total billed charges,48.48% of total billed charges,649.8,90,,519.84,percent of total billed charges,90% of total billed charges,48.48,649.8,
PELVIS/HIP INFANT 2 VW,42001069,CDM,320,RC,73521,HCPCS,outpatient,,,465,279.00,TC,279,60,,223.2,percent of total billed charges,60% of total billed charges,223.2,48,,178.56,percent of total billed charges,48% of total billed charges,45.31,100,,,fee schedule,100% of bcbs custom fee schedule,45.31,100,,,fee schedule,100% of bcbs custom fee schedule,50.29,111,,,fee schedule,111% of bcbs custom fee schedule,232.5,50,,186,percent of total billed charges,50% of total billed charges,325.5,70,,260.4,percent of total billed charges,70% of total billed charges,225.43,48.48,,180.344,percent of total billed charges,48.48% of total billed charges,43.25,116.15,,,fee schedule,116.51% of cms physician fee schedule,225.43,48.48,,180.344,percent of total billed charges,48.48% of total billed charges,325.5,70,,260.4,percent of total billed charges,70% of total billed charges,325.5,70,,260.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,225.43,48.48,,180.344,percent of total billed charges,48.48% of total billed charges,418.5,90,,334.8,percent of total billed charges,90% of total billed charges,48.48,418.5,
FEMUR AP/LAT,42000301,CDM,320,RC,73552,HCPCS,outpatient,,,378,226.80,TC,226.8,60,,181.44,percent of total billed charges,60% of total billed charges,181.44,48,,145.152,percent of total billed charges,48% of total billed charges,36.69,100,,,fee schedule,100% of bcbs custom fee schedule,36.69,100,,,fee schedule,100% of bcbs custom fee schedule,40.73,111,,,fee schedule,111% of bcbs custom fee schedule,189,50,,151.2,percent of total billed charges,50% of total billed charges,264.6,70,,211.68,percent of total billed charges,70% of total billed charges,183.25,48.48,,146.6,percent of total billed charges,48.48% of total billed charges,37.31,116.15,,,fee schedule,116.51% of cms physician fee schedule,183.25,48.48,,146.6,percent of total billed charges,48.48% of total billed charges,264.6,70,,211.68,percent of total billed charges,70% of total billed charges,264.6,70,,211.68,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,183.25,48.48,,146.6,percent of total billed charges,48.48% of total billed charges,340.2,90,,272.16,percent of total billed charges,90% of total billed charges,48.48,340.2,
KNEE AP/LAT,42000431,CDM,320,RC,73560,HCPCS,outpatient,,,361,216.60,TC,216.6,60,,173.28,percent of total billed charges,60% of total billed charges,173.28,48,,138.624,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,180.5,50,,144.4,percent of total billed charges,50% of total billed charges,252.7,70,,202.16,percent of total billed charges,70% of total billed charges,175.01,48.48,,140.008,percent of total billed charges,48.48% of total billed charges,35.86,116.15,,,fee schedule,116.51% of cms physician fee schedule,175.01,48.48,,140.008,percent of total billed charges,48.48% of total billed charges,252.7,70,,202.16,percent of total billed charges,70% of total billed charges,252.7,70,,202.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,175.01,48.48,,140.008,percent of total billed charges,48.48% of total billed charges,324.9,90,,259.92,percent of total billed charges,90% of total billed charges,48.48,324.9,
KNEE THREE VIEWS LT,42000441,CDM,320,RC,73562,HCPCS,outpatient,,,415,249.00,TC,31,100,,,fee schedule,100% of aetna fee schedule,199.2,48,,159.36,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,207.5,50,,166,percent of total billed charges,50% of total billed charges,290.5,70,,232.4,percent of total billed charges,70% of total billed charges,201.19,48.48,,160.952,percent of total billed charges,48.48% of total billed charges,42.72,116.15,,,fee schedule,116.51% of cms physician fee schedule,201.19,48.48,,160.952,percent of total billed charges,48.48% of total billed charges,290.5,70,,232.4,percent of total billed charges,70% of total billed charges,290.5,70,,232.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,201.19,48.48,,160.952,percent of total billed charges,48.48% of total billed charges,373.5,90,,298.8,percent of total billed charges,90% of total billed charges,48.48,373.5,
KNEE 3 VIEW RT,42000441,CDM,320,RC,73562,HCPCS,outpatient,,,415,249.00,TC,31,100,,,fee schedule,100% of aetna fee schedule,199.2,48,,159.36,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,207.5,50,,166,percent of total billed charges,50% of total billed charges,290.5,70,,232.4,percent of total billed charges,70% of total billed charges,201.19,48.48,,160.952,percent of total billed charges,48.48% of total billed charges,42.72,116.15,,,fee schedule,116.51% of cms physician fee schedule,201.19,48.48,,160.952,percent of total billed charges,48.48% of total billed charges,290.5,70,,232.4,percent of total billed charges,70% of total billed charges,290.5,70,,232.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,201.19,48.48,,160.952,percent of total billed charges,48.48% of total billed charges,373.5,90,,298.8,percent of total billed charges,90% of total billed charges,48.48,373.5,
KNEE BILAT STANDING,42000445,CDM,320,RC,73565,HCPCS,outpatient,,,623,373.80,TC,373.8,60,,299.04,percent of total billed charges,60% of total billed charges,299.04,48,,239.232,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,311.5,50,,249.2,percent of total billed charges,50% of total billed charges,436.1,70,,348.88,percent of total billed charges,70% of total billed charges,302.03,48.48,,241.624,percent of total billed charges,48.48% of total billed charges,41.62,116.15,,,fee schedule,116.51% of cms physician fee schedule,302.03,48.48,,241.624,percent of total billed charges,48.48% of total billed charges,436.1,70,,348.88,percent of total billed charges,70% of total billed charges,436.1,70,,348.88,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,302.03,48.48,,241.624,percent of total billed charges,48.48% of total billed charges,560.7,90,,448.56,percent of total billed charges,90% of total billed charges,48.48,560.7,
TIB/FIB 2 VIEWS,42000801,CDM,320,RC,73590,HCPCS,outpatient,,,332,199.20,TC,199.2,60,,159.36,percent of total billed charges,60% of total billed charges,159.36,48,,127.488,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,166,50,,132.8,percent of total billed charges,50% of total billed charges,232.4,70,,185.92,percent of total billed charges,70% of total billed charges,160.95,48.48,,128.76,percent of total billed charges,48.48% of total billed charges,33.15,116.15,,,fee schedule,116.51% of cms physician fee schedule,160.95,48.48,,128.76,percent of total billed charges,48.48% of total billed charges,232.4,70,,185.92,percent of total billed charges,70% of total billed charges,232.4,70,,185.92,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,160.95,48.48,,128.76,percent of total billed charges,48.48% of total billed charges,298.8,90,,239.04,percent of total billed charges,90% of total billed charges,48.48,298.8,
LOWER EXT(INFANT) 2 VW,42000476,CDM,320,RC,73592,HCPCS,outpatient,,,324,194.40,TC,194.4,60,,155.52,percent of total billed charges,60% of total billed charges,155.52,48,,124.416,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,162,50,,129.6,percent of total billed charges,50% of total billed charges,226.8,70,,181.44,percent of total billed charges,70% of total billed charges,157.08,48.48,,125.664,percent of total billed charges,48.48% of total billed charges,33.15,116.15,,,fee schedule,116.51% of cms physician fee schedule,157.08,48.48,,125.664,percent of total billed charges,48.48% of total billed charges,226.8,70,,181.44,percent of total billed charges,70% of total billed charges,226.8,70,,181.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,157.08,48.48,,125.664,percent of total billed charges,48.48% of total billed charges,291.6,90,,233.28,percent of total billed charges,90% of total billed charges,48.48,291.6,
ANKLE 2 VIEWS,42000031,CDM,320,RC,73600,HCPCS,outpatient,,,349,209.40,TC,209.4,60,,167.52,percent of total billed charges,60% of total billed charges,167.52,48,,134.016,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,174.5,50,,139.6,percent of total billed charges,50% of total billed charges,244.3,70,,195.44,percent of total billed charges,70% of total billed charges,169.2,48.48,,135.36,percent of total billed charges,48.48% of total billed charges,33.82,116.15,,,fee schedule,116.51% of cms physician fee schedule,169.2,48.48,,135.36,percent of total billed charges,48.48% of total billed charges,244.3,70,,195.44,percent of total billed charges,70% of total billed charges,244.3,70,,195.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,169.2,48.48,,135.36,percent of total billed charges,48.48% of total billed charges,314.1,90,,251.28,percent of total billed charges,90% of total billed charges,48.48,314.1,
ANKLE 3 VIEWS LT,42000036,CDM,320,RC,73610,HCPCS,outpatient,,,365,219.00,TC,29,100,,,fee schedule,100% of aetna fee schedule,175.2,48,,140.16,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,182.5,50,,146,percent of total billed charges,50% of total billed charges,255.5,70,,204.4,percent of total billed charges,70% of total billed charges,176.95,48.48,,141.56,percent of total billed charges,48.48% of total billed charges,38.27,116.15,,,fee schedule,116.51% of cms physician fee schedule,176.95,48.48,,141.56,percent of total billed charges,48.48% of total billed charges,255.5,70,,204.4,percent of total billed charges,70% of total billed charges,255.5,70,,204.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,176.95,48.48,,141.56,percent of total billed charges,48.48% of total billed charges,328.5,90,,262.8,percent of total billed charges,90% of total billed charges,48.48,328.5,
FOOT 2 VIEWS LT,42000341,CDM,320,RC,73620,HCPCS,outpatient,,,303,181.80,TC,181.8,60,,145.44,percent of total billed charges,60% of total billed charges,145.44,48,,116.352,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,151.5,50,,121.2,percent of total billed charges,50% of total billed charges,212.1,70,,169.68,percent of total billed charges,70% of total billed charges,146.89,48.48,,117.512,percent of total billed charges,48.48% of total billed charges,30.09,116.15,,,fee schedule,116.51% of cms physician fee schedule,146.89,48.48,,117.512,percent of total billed charges,48.48% of total billed charges,212.1,70,,169.68,percent of total billed charges,70% of total billed charges,212.1,70,,169.68,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,146.89,48.48,,117.512,percent of total billed charges,48.48% of total billed charges,272.7,90,,218.16,percent of total billed charges,90% of total billed charges,48.48,272.7,
FOOT 3V BILATERAL,42000336,CDM,320,RC,73630,HCPCS,outpatient,,,510,306.00,TC,29,100,,,fee schedule,100% of aetna fee schedule,244.8,48,,195.84,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,255,50,,204,percent of total billed charges,50% of total billed charges,357,70,,285.6,percent of total billed charges,70% of total billed charges,247.25,48.48,,197.8,percent of total billed charges,48.48% of total billed charges,35.9,116.15,,,fee schedule,116.51% of cms physician fee schedule,247.25,48.48,,197.8,percent of total billed charges,48.48% of total billed charges,357,70,,285.6,percent of total billed charges,70% of total billed charges,357,70,,285.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,247.25,48.48,,197.8,percent of total billed charges,48.48% of total billed charges,459,90,,367.2,percent of total billed charges,90% of total billed charges,48.48,459,
FOOT 3 VIEWS LT,42000336,CDM,320,RC,73630,HCPCS,outpatient,,,340,204.00,TC,29,100,,,fee schedule,100% of aetna fee schedule,163.2,48,,130.56,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,170,50,,136,percent of total billed charges,50% of total billed charges,238,70,,190.4,percent of total billed charges,70% of total billed charges,164.83,48.48,,131.864,percent of total billed charges,48.48% of total billed charges,35.9,116.15,,,fee schedule,116.51% of cms physician fee schedule,164.83,48.48,,131.864,percent of total billed charges,48.48% of total billed charges,238,70,,190.4,percent of total billed charges,70% of total billed charges,238,70,,190.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,164.83,48.48,,131.864,percent of total billed charges,48.48% of total billed charges,306,90,,244.8,percent of total billed charges,90% of total billed charges,48.48,306,
CALCANEOUS 2 VIEWS,42000611,CDM,320,RC,73650,HCPCS,outpatient,,,315,189.00,TC,189,60,,151.2,percent of total billed charges,60% of total billed charges,151.2,48,,120.96,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,157.5,50,,126,percent of total billed charges,50% of total billed charges,220.5,70,,176.4,percent of total billed charges,70% of total billed charges,152.71,48.48,,122.168,percent of total billed charges,48.48% of total billed charges,30.09,116.15,,,fee schedule,116.51% of cms physician fee schedule,152.71,48.48,,122.168,percent of total billed charges,48.48% of total billed charges,220.5,70,,176.4,percent of total billed charges,70% of total billed charges,220.5,70,,176.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,152.71,48.48,,122.168,percent of total billed charges,48.48% of total billed charges,283.5,90,,226.8,percent of total billed charges,90% of total billed charges,48.48,283.5,
TOES 2 VIEWS,42000970,CDM,320,RC,73660,HCPCS,outpatient,,,328,196.80,TC,196.8,60,,157.44,percent of total billed charges,60% of total billed charges,157.44,48,,125.952,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,164,50,,131.2,percent of total billed charges,50% of total billed charges,229.6,70,,183.68,percent of total billed charges,70% of total billed charges,159.01,48.48,,127.208,percent of total billed charges,48.48% of total billed charges,30.63,116.15,,,fee schedule,116.51% of cms physician fee schedule,159.01,48.48,,127.208,percent of total billed charges,48.48% of total billed charges,229.6,70,,183.68,percent of total billed charges,70% of total billed charges,229.6,70,,183.68,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,159.01,48.48,,127.208,percent of total billed charges,48.48% of total billed charges,295.2,90,,236.16,percent of total billed charges,90% of total billed charges,48.48,295.2,
ABD 1 VIEW,42000010,CDM,320,RC,74018,HCPCS,outpatient,,,274,164.40,TC,164.4,60,,131.52,percent of total billed charges,60% of total billed charges,131.52,48,,105.216,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,137,50,,109.6,percent of total billed charges,50% of total billed charges,191.8,70,,153.44,percent of total billed charges,70% of total billed charges,132.84,48.48,,106.272,percent of total billed charges,48.48% of total billed charges,31.88,116.15,,,fee schedule,116.51% of cms physician fee schedule,132.84,48.48,,106.272,percent of total billed charges,48.48% of total billed charges,191.8,70,,153.44,percent of total billed charges,70% of total billed charges,191.8,70,,153.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,132.84,48.48,,106.272,percent of total billed charges,48.48% of total billed charges,246.6,90,,197.28,percent of total billed charges,90% of total billed charges,48.48,246.6,
ABD 2V  FLAT/ERECT CMPLTE,42000015,CDM,320,RC,74019,HCPCS,outpatient,,,432,259.20,TC,259.2,60,,207.36,percent of total billed charges,60% of total billed charges,207.36,48,,165.888,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,216,50,,172.8,percent of total billed charges,50% of total billed charges,302.4,70,,241.92,percent of total billed charges,70% of total billed charges,209.43,48.48,,167.544,percent of total billed charges,48.48% of total billed charges,38.56,116.15,,,fee schedule,116.51% of cms physician fee schedule,209.43,48.48,,167.544,percent of total billed charges,48.48% of total billed charges,302.4,70,,241.92,percent of total billed charges,70% of total billed charges,302.4,70,,241.92,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,209.43,48.48,,167.544,percent of total billed charges,48.48% of total billed charges,388.8,90,,311.04,percent of total billed charges,90% of total billed charges,48.48,388.8,
ABD SERIES COMPLETE,42000025,CDM,320,RC,74022,HCPCS,outpatient,,,519,311.40,TC,311.4,60,,249.12,percent of total billed charges,60% of total billed charges,249.12,48,,199.296,percent of total billed charges,48% of total billed charges,109.7,100,,,fee schedule,100% of bcbs custom fee schedule,109.7,100,,,fee schedule,100% of bcbs custom fee schedule,121.77,111,,,fee schedule,111% of bcbs custom fee schedule,259.5,50,,207.6,percent of total billed charges,50% of total billed charges,363.3,70,,290.64,percent of total billed charges,70% of total billed charges,251.61,48.48,,201.288,percent of total billed charges,48.48% of total billed charges,52.64,116.15,,,fee schedule,116.51% of cms physician fee schedule,251.61,48.48,,201.288,percent of total billed charges,48.48% of total billed charges,363.3,70,,290.64,percent of total billed charges,70% of total billed charges,363.3,70,,290.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,251.61,48.48,,201.288,percent of total billed charges,48.48% of total billed charges,467.1,90,,373.68,percent of total billed charges,90% of total billed charges,48.48,467.1,
MRI ABDOMEN W/O DYE,42004030,CDM,614,RC,74181,HCPCS,outpatient,,,2802,1681.20,TC,1681.2,60,,1344.96,percent of total billed charges,60% of total billed charges,1344.96,48,,1075.968,percent of total billed charges,48% of total billed charges,707.65,100,,,fee schedule,100% of bcbs custom fee schedule,707.65,100,,,fee schedule,100% of bcbs custom fee schedule,785.49,111,,,fee schedule,111% of bcbs custom fee schedule,600,100,,,case rate,pays based on per visit rate,1961.4,70,,1569.12,percent of total billed charges,70% of total billed charges,1358.41,48.48,,1086.728,percent of total billed charges,48.48% of total billed charges,212.6,116.15,,,fee schedule,116.51% of cms physician fee schedule,1358.41,48.48,,1086.728,percent of total billed charges,48.48% of total billed charges,1961.4,70,,1569.12,percent of total billed charges,70% of total billed charges,1961.4,70,,1569.12,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,1358.41,48.48,,1086.728,percent of total billed charges,48.48% of total billed charges,2521.8,90,,2017.44,percent of total billed charges,90% of total billed charges,48.48,2521.8,
SPIROMETRY - RAD,43102036,CDM,460,RC,94010,HCPCS,outpatient,,,225,135.00,,32,100,,,fee schedule,100% of aetna fee schedule,108,48,,86.4,percent of total billed charges,48% of total billed charges,125.28,100,,,fee schedule,100% of bcbs custom fee schedule,125.28,100,,,fee schedule,100% of bcbs custom fee schedule,139.06,111,,,fee schedule,111% of bcbs custom fee schedule,112.5,50,,90,percent of total billed charges,50% of total billed charges,157.5,70,,126,percent of total billed charges,70% of total billed charges,109.08,48.48,,87.264,percent of total billed charges,48.48% of total billed charges,28.79,116.15,,,fee schedule,116.51% of cms physician fee schedule,109.08,48.48,,87.264,percent of total billed charges,48.48% of total billed charges,157.5,70,,126,percent of total billed charges,70% of total billed charges,157.5,70,,126,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,109.08,48.48,,87.264,percent of total billed charges,48.48% of total billed charges,202.5,90,,162,percent of total billed charges,90% of total billed charges,48.48,202.5,
RIBS UNILAT 2 VIEWS RT,42000676,CDM,320,RC,71100,HCPCS,outpatient,,,382,229.20,TC,229.2,60,,183.36,percent of total billed charges,60% of total billed charges,183.36,48,,146.688,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,191,50,,152.8,percent of total billed charges,50% of total billed charges,267.4,70,,213.92,percent of total billed charges,70% of total billed charges,185.19,48.48,,148.152,percent of total billed charges,48.48% of total billed charges,38.52,116.15,,,fee schedule,116.51% of cms physician fee schedule,185.19,48.48,,148.152,percent of total billed charges,48.48% of total billed charges,267.4,70,,213.92,percent of total billed charges,70% of total billed charges,267.4,70,,213.92,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,185.19,48.48,,148.152,percent of total billed charges,48.48% of total billed charges,343.8,90,,275.04,percent of total billed charges,90% of total billed charges,48.48,343.8,
CLAVICLE 2 VIEW RT,42000206,CDM,320,RC,73000,HCPCS,outpatient,,,320,192.00,TC,192,60,,153.6,percent of total billed charges,60% of total billed charges,153.6,48,,122.88,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,160,50,,128,percent of total billed charges,50% of total billed charges,224,70,,179.2,percent of total billed charges,70% of total billed charges,155.14,48.48,,124.112,percent of total billed charges,48.48% of total billed charges,34.16,116.15,,,fee schedule,116.51% of cms physician fee schedule,155.14,48.48,,124.112,percent of total billed charges,48.48% of total billed charges,224,70,,179.2,percent of total billed charges,70% of total billed charges,224,70,,179.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,155.14,48.48,,124.112,percent of total billed charges,48.48% of total billed charges,288,90,,230.4,percent of total billed charges,90% of total billed charges,48.48,288,
SHOULDER ONE VIEW,42000281,CDM,320,RC,73020,HCPCS,outpatient,,,266,159.60,TC,159.6,60,,127.68,percent of total billed charges,60% of total billed charges,127.68,48,,102.144,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,133,50,,106.4,percent of total billed charges,50% of total billed charges,186.2,70,,148.96,percent of total billed charges,70% of total billed charges,128.96,48.48,,103.168,percent of total billed charges,48.48% of total billed charges,22.94,116.15,,,fee schedule,116.51% of cms physician fee schedule,128.96,48.48,,103.168,percent of total billed charges,48.48% of total billed charges,186.2,70,,148.96,percent of total billed charges,70% of total billed charges,186.2,70,,148.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,128.96,48.48,,103.168,percent of total billed charges,48.48% of total billed charges,239.4,90,,191.52,percent of total billed charges,90% of total billed charges,48.48,239.4,
SHOULDER MIN 2 VIEWS RT,42000716,CDM,320,RC,73030,HCPCS,outpatient,,,336,201.60,TC,31,100,,,fee schedule,100% of aetna fee schedule,161.28,48,,129.024,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,168,50,,134.4,percent of total billed charges,50% of total billed charges,235.2,70,,188.16,percent of total billed charges,70% of total billed charges,162.89,48.48,,130.312,percent of total billed charges,48.48% of total billed charges,36.62,116.15,,,fee schedule,116.51% of cms physician fee schedule,162.89,48.48,,130.312,percent of total billed charges,48.48% of total billed charges,235.2,70,,188.16,percent of total billed charges,70% of total billed charges,235.2,70,,188.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,162.89,48.48,,130.312,percent of total billed charges,48.48% of total billed charges,302.4,90,,241.92,percent of total billed charges,90% of total billed charges,48.48,302.4,
HUMERUS MIN 2 VIEWS RT,42000381,CDM,320,RC,73060,HCPCS,outpatient,,,336,201.60,TC,201.6,60,,161.28,percent of total billed charges,60% of total billed charges,161.28,48,,129.024,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,168,50,,134.4,percent of total billed charges,50% of total billed charges,235.2,70,,188.16,percent of total billed charges,70% of total billed charges,162.89,48.48,,130.312,percent of total billed charges,48.48% of total billed charges,33.49,116.15,,,fee schedule,116.51% of cms physician fee schedule,162.89,48.48,,130.312,percent of total billed charges,48.48% of total billed charges,235.2,70,,188.16,percent of total billed charges,70% of total billed charges,235.2,70,,188.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,162.89,48.48,,130.312,percent of total billed charges,48.48% of total billed charges,302.4,90,,241.92,percent of total billed charges,90% of total billed charges,48.48,302.4,
ELBOW 2 VIEWS RT,42000266,CDM,320,RC,73070,HCPCS,outpatient,,,320,192.00,TC,192,60,,153.6,percent of total billed charges,60% of total billed charges,153.6,48,,122.88,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,160,50,,128,percent of total billed charges,50% of total billed charges,224,70,,179.2,percent of total billed charges,70% of total billed charges,155.14,48.48,,124.112,percent of total billed charges,48.48% of total billed charges,30.77,116.15,,,fee schedule,116.51% of cms physician fee schedule,155.14,48.48,,124.112,percent of total billed charges,48.48% of total billed charges,224,70,,179.2,percent of total billed charges,70% of total billed charges,224,70,,179.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,155.14,48.48,,124.112,percent of total billed charges,48.48% of total billed charges,288,90,,230.4,percent of total billed charges,90% of total billed charges,48.48,288,
ELBOW BILATERAL,42000266,CDM,320,RC,73070,HCPCS,outpatient,,,479,287.40,TC,287.4,60,,229.92,percent of total billed charges,60% of total billed charges,229.92,48,,183.936,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,239.5,50,,191.6,percent of total billed charges,50% of total billed charges,335.3,70,,268.24,percent of total billed charges,70% of total billed charges,232.22,48.48,,185.776,percent of total billed charges,48.48% of total billed charges,30.77,116.15,,,fee schedule,116.51% of cms physician fee schedule,232.22,48.48,,185.776,percent of total billed charges,48.48% of total billed charges,335.3,70,,268.24,percent of total billed charges,70% of total billed charges,335.3,70,,268.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,232.22,48.48,,185.776,percent of total billed charges,48.48% of total billed charges,431.1,90,,344.88,percent of total billed charges,90% of total billed charges,48.48,431.1,
ELBOW COMP 3 VW,42000271,CDM,320,RC,73080,HCPCS,outpatient,,,361,216.60,TC,216.6,60,,173.28,percent of total billed charges,60% of total billed charges,173.28,48,,138.624,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,180.5,50,,144.4,percent of total billed charges,50% of total billed charges,252.7,70,,202.16,percent of total billed charges,70% of total billed charges,175.01,48.48,,140.008,percent of total billed charges,48.48% of total billed charges,34.54,116.15,,,fee schedule,116.51% of cms physician fee schedule,175.01,48.48,,140.008,percent of total billed charges,48.48% of total billed charges,252.7,70,,202.16,percent of total billed charges,70% of total billed charges,252.7,70,,202.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,175.01,48.48,,140.008,percent of total billed charges,48.48% of total billed charges,324.9,90,,259.92,percent of total billed charges,90% of total billed charges,48.48,324.9,
FOREARM 2 VIEWS RT,42000346,CDM,320,RC,73090,HCPCS,outpatient,,,299,179.40,TC,179.4,60,,143.52,percent of total billed charges,60% of total billed charges,143.52,48,,114.816,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,149.5,50,,119.6,percent of total billed charges,50% of total billed charges,209.3,70,,167.44,percent of total billed charges,70% of total billed charges,144.96,48.48,,115.968,percent of total billed charges,48.48% of total billed charges,30.77,116.15,,,fee schedule,116.51% of cms physician fee schedule,144.96,48.48,,115.968,percent of total billed charges,48.48% of total billed charges,209.3,70,,167.44,percent of total billed charges,70% of total billed charges,209.3,70,,167.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,144.96,48.48,,115.968,percent of total billed charges,48.48% of total billed charges,269.1,90,,215.28,percent of total billed charges,90% of total billed charges,48.48,269.1,
WRIST 2 VIEWS RT,42000886,CDM,320,RC,73100,HCPCS,outpatient,,,340,204.00,TC,204,60,,163.2,percent of total billed charges,60% of total billed charges,163.2,48,,130.56,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,170,50,,136,percent of total billed charges,50% of total billed charges,238,70,,190.4,percent of total billed charges,70% of total billed charges,164.83,48.48,,131.864,percent of total billed charges,48.48% of total billed charges,35.52,116.15,,,fee schedule,116.51% of cms physician fee schedule,164.83,48.48,,131.864,percent of total billed charges,48.48% of total billed charges,238,70,,190.4,percent of total billed charges,70% of total billed charges,238,70,,190.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,164.83,48.48,,131.864,percent of total billed charges,48.48% of total billed charges,306,90,,244.8,percent of total billed charges,90% of total billed charges,48.48,306,
WRIST 3 VIEWS RT,42000892,CDM,320,RC,73110,HCPCS,outpatient,,,411,246.60,TC,29,100,,,fee schedule,100% of aetna fee schedule,197.28,48,,157.824,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,205.5,50,,164.4,percent of total billed charges,50% of total billed charges,287.7,70,,230.16,percent of total billed charges,70% of total billed charges,199.25,48.48,,159.4,percent of total billed charges,48.48% of total billed charges,43.01,116.15,,,fee schedule,116.51% of cms physician fee schedule,199.25,48.48,,159.4,percent of total billed charges,48.48% of total billed charges,287.7,70,,230.16,percent of total billed charges,70% of total billed charges,287.7,70,,230.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,199.25,48.48,,159.4,percent of total billed charges,48.48% of total billed charges,369.9,90,,295.92,percent of total billed charges,90% of total billed charges,48.48,369.9,
HAND 2 VIEWS RT,42000356,CDM,320,RC,73120,HCPCS,outpatient,,,303,181.80,TC,181.8,60,,145.44,percent of total billed charges,60% of total billed charges,145.44,48,,116.352,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,151.5,50,,121.2,percent of total billed charges,50% of total billed charges,212.1,70,,169.68,percent of total billed charges,70% of total billed charges,146.89,48.48,,117.512,percent of total billed charges,48.48% of total billed charges,33.15,116.15,,,fee schedule,116.51% of cms physician fee schedule,146.89,48.48,,117.512,percent of total billed charges,48.48% of total billed charges,212.1,70,,169.68,percent of total billed charges,70% of total billed charges,212.1,70,,169.68,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,146.89,48.48,,117.512,percent of total billed charges,48.48% of total billed charges,272.7,90,,218.16,percent of total billed charges,90% of total billed charges,48.48,272.7,
HAND 3 VIEWS RT,42000361,CDM,320,RC,73130,HCPCS,outpatient,,,357,214.20,TC,29,100,,,fee schedule,100% of aetna fee schedule,171.36,48,,137.088,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,178.5,50,,142.8,percent of total billed charges,50% of total billed charges,249.9,70,,199.92,percent of total billed charges,70% of total billed charges,173.07,48.48,,138.456,percent of total billed charges,48.48% of total billed charges,38.95,116.15,,,fee schedule,116.51% of cms physician fee schedule,173.07,48.48,,138.456,percent of total billed charges,48.48% of total billed charges,249.9,70,,199.92,percent of total billed charges,70% of total billed charges,249.9,70,,199.92,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,173.07,48.48,,138.456,percent of total billed charges,48.48% of total billed charges,321.3,90,,257.04,percent of total billed charges,90% of total billed charges,48.48,321.3,
HAND BILATERAL,42000361,CDM,320,RC,73130,HCPCS,outpatient,,,454,272.40,TC,29,100,,,fee schedule,100% of aetna fee schedule,217.92,48,,174.336,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,227,50,,181.6,percent of total billed charges,50% of total billed charges,317.8,70,,254.24,percent of total billed charges,70% of total billed charges,220.1,48.48,,176.08,percent of total billed charges,48.48% of total billed charges,38.95,116.15,,,fee schedule,116.51% of cms physician fee schedule,220.1,48.48,,176.08,percent of total billed charges,48.48% of total billed charges,317.8,70,,254.24,percent of total billed charges,70% of total billed charges,317.8,70,,254.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,220.1,48.48,,176.08,percent of total billed charges,48.48% of total billed charges,408.6,90,,326.88,percent of total billed charges,90% of total billed charges,48.48,408.6,
FINGER 2 VIEW,42000910,CDM,320,RC,73140,HCPCS,outpatient,,,365,219.00,TC,219,60,,175.2,percent of total billed charges,60% of total billed charges,175.2,48,,140.16,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,182.5,50,,146,percent of total billed charges,50% of total billed charges,255.5,70,,204.4,percent of total billed charges,70% of total billed charges,176.95,48.48,,141.56,percent of total billed charges,48.48% of total billed charges,39.77,116.15,,,fee schedule,116.51% of cms physician fee schedule,176.95,48.48,,141.56,percent of total billed charges,48.48% of total billed charges,255.5,70,,204.4,percent of total billed charges,70% of total billed charges,255.5,70,,204.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,176.95,48.48,,141.56,percent of total billed charges,48.48% of total billed charges,328.5,90,,262.8,percent of total billed charges,90% of total billed charges,48.48,328.5,
HIP UNILAT 1 VW RT,42001063,CDM,320,RC,73501,HCPCS,outpatient,,,349,209.40,TC,209.4,60,,167.52,percent of total billed charges,60% of total billed charges,167.52,48,,134.016,percent of total billed charges,48% of total billed charges,32.68,100,,,fee schedule,100% of bcbs custom fee schedule,32.68,100,,,fee schedule,100% of bcbs custom fee schedule,36.27,111,,,fee schedule,111% of bcbs custom fee schedule,174.5,50,,139.6,percent of total billed charges,50% of total billed charges,244.3,70,,195.44,percent of total billed charges,70% of total billed charges,169.2,48.48,,135.36,percent of total billed charges,48.48% of total billed charges,34.59,116.15,,,fee schedule,116.51% of cms physician fee schedule,169.2,48.48,,135.36,percent of total billed charges,48.48% of total billed charges,244.3,70,,195.44,percent of total billed charges,70% of total billed charges,244.3,70,,195.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,169.2,48.48,,135.36,percent of total billed charges,48.48% of total billed charges,314.1,90,,251.28,percent of total billed charges,90% of total billed charges,48.48,314.1,
HIP UNILAT 2 VW RT,42001065,CDM,320,RC,73502,HCPCS,outpatient,,,481,288.60,TC,288.6,60,,230.88,percent of total billed charges,60% of total billed charges,230.88,48,,184.704,percent of total billed charges,48% of total billed charges,48.17,100,,,fee schedule,100% of bcbs custom fee schedule,48.17,100,,,fee schedule,100% of bcbs custom fee schedule,53.47,111,,,fee schedule,111% of bcbs custom fee schedule,240.5,50,,192.4,percent of total billed charges,50% of total billed charges,336.7,70,,269.36,percent of total billed charges,70% of total billed charges,233.19,48.48,,186.552,percent of total billed charges,48.48% of total billed charges,49.69,116.15,,,fee schedule,116.51% of cms physician fee schedule,233.19,48.48,,186.552,percent of total billed charges,48.48% of total billed charges,336.7,70,,269.36,percent of total billed charges,70% of total billed charges,336.7,70,,269.36,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,233.19,48.48,,186.552,percent of total billed charges,48.48% of total billed charges,432.9,90,,346.32,percent of total billed charges,90% of total billed charges,48.48,432.9,
FEMUR 1 VIEW,42001089,CDM,320,RC,73551,HCPCS,outpatient,,,465,279.00,TC,279,60,,223.2,percent of total billed charges,60% of total billed charges,223.2,48,,178.56,percent of total billed charges,48% of total billed charges,30.95,100,,,fee schedule,100% of bcbs custom fee schedule,30.95,100,,,fee schedule,100% of bcbs custom fee schedule,34.35,111,,,fee schedule,111% of bcbs custom fee schedule,232.5,50,,186,percent of total billed charges,50% of total billed charges,325.5,70,,260.4,percent of total billed charges,70% of total billed charges,225.43,48.48,,180.344,percent of total billed charges,48.48% of total billed charges,30.77,116.15,,,fee schedule,116.51% of cms physician fee schedule,225.43,48.48,,180.344,percent of total billed charges,48.48% of total billed charges,325.5,70,,260.4,percent of total billed charges,70% of total billed charges,325.5,70,,260.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,225.43,48.48,,180.344,percent of total billed charges,48.48% of total billed charges,418.5,90,,334.8,percent of total billed charges,90% of total billed charges,48.48,418.5,
KNEE AP/LAT RT,42000431,CDM,320,RC,73560,HCPCS,outpatient,,,361,216.60,TC,216.6,60,,173.28,percent of total billed charges,60% of total billed charges,173.28,48,,138.624,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,180.5,50,,144.4,percent of total billed charges,50% of total billed charges,252.7,70,,202.16,percent of total billed charges,70% of total billed charges,175.01,48.48,,140.008,percent of total billed charges,48.48% of total billed charges,35.86,116.15,,,fee schedule,116.51% of cms physician fee schedule,175.01,48.48,,140.008,percent of total billed charges,48.48% of total billed charges,252.7,70,,202.16,percent of total billed charges,70% of total billed charges,252.7,70,,202.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,175.01,48.48,,140.008,percent of total billed charges,48.48% of total billed charges,324.9,90,,259.92,percent of total billed charges,90% of total billed charges,48.48,324.9,
TIB/FIB 2 VIEWS RT,42000801,CDM,320,RC,73590,HCPCS,outpatient,,,332,199.20,TC,199.2,60,,159.36,percent of total billed charges,60% of total billed charges,159.36,48,,127.488,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,166,50,,132.8,percent of total billed charges,50% of total billed charges,232.4,70,,185.92,percent of total billed charges,70% of total billed charges,160.95,48.48,,128.76,percent of total billed charges,48.48% of total billed charges,33.15,116.15,,,fee schedule,116.51% of cms physician fee schedule,160.95,48.48,,128.76,percent of total billed charges,48.48% of total billed charges,232.4,70,,185.92,percent of total billed charges,70% of total billed charges,232.4,70,,185.92,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,160.95,48.48,,128.76,percent of total billed charges,48.48% of total billed charges,298.8,90,,239.04,percent of total billed charges,90% of total billed charges,48.48,298.8,
ANKLE 3 VIEWS RT,42000036,CDM,320,RC,73610,HCPCS,outpatient,,,365,219.00,TC,29,100,,,fee schedule,100% of aetna fee schedule,175.2,48,,140.16,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,182.5,50,,146,percent of total billed charges,50% of total billed charges,255.5,70,,204.4,percent of total billed charges,70% of total billed charges,176.95,48.48,,141.56,percent of total billed charges,48.48% of total billed charges,38.27,116.15,,,fee schedule,116.51% of cms physician fee schedule,176.95,48.48,,141.56,percent of total billed charges,48.48% of total billed charges,255.5,70,,204.4,percent of total billed charges,70% of total billed charges,255.5,70,,204.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,176.95,48.48,,141.56,percent of total billed charges,48.48% of total billed charges,328.5,90,,262.8,percent of total billed charges,90% of total billed charges,48.48,328.5,
ANKLE BILATERAL,42000036,CDM,320,RC,73610,HCPCS,outpatient,,,548,328.80,TC,29,100,,,fee schedule,100% of aetna fee schedule,263.04,48,,210.432,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,274,50,,219.2,percent of total billed charges,50% of total billed charges,383.6,70,,306.88,percent of total billed charges,70% of total billed charges,265.67,48.48,,212.536,percent of total billed charges,48.48% of total billed charges,38.27,116.15,,,fee schedule,116.51% of cms physician fee schedule,265.67,48.48,,212.536,percent of total billed charges,48.48% of total billed charges,383.6,70,,306.88,percent of total billed charges,70% of total billed charges,383.6,70,,306.88,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,265.67,48.48,,212.536,percent of total billed charges,48.48% of total billed charges,493.2,90,,394.56,percent of total billed charges,90% of total billed charges,48.48,493.2,
FOOT 2 VIEWS RT,42000341,CDM,320,RC,73620,HCPCS,outpatient,,,303,181.80,TC,181.8,60,,145.44,percent of total billed charges,60% of total billed charges,145.44,48,,116.352,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,151.5,50,,121.2,percent of total billed charges,50% of total billed charges,212.1,70,,169.68,percent of total billed charges,70% of total billed charges,146.89,48.48,,117.512,percent of total billed charges,48.48% of total billed charges,30.09,116.15,,,fee schedule,116.51% of cms physician fee schedule,146.89,48.48,,117.512,percent of total billed charges,48.48% of total billed charges,212.1,70,,169.68,percent of total billed charges,70% of total billed charges,212.1,70,,169.68,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,146.89,48.48,,117.512,percent of total billed charges,48.48% of total billed charges,272.7,90,,218.16,percent of total billed charges,90% of total billed charges,48.48,272.7,
FOOT 3 VIEWS RT,42000336,CDM,320,RC,73630,HCPCS,outpatient,,,340,204.00,TC,29,100,,,fee schedule,100% of aetna fee schedule,163.2,48,,130.56,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,170,50,,136,percent of total billed charges,50% of total billed charges,238,70,,190.4,percent of total billed charges,70% of total billed charges,164.83,48.48,,131.864,percent of total billed charges,48.48% of total billed charges,35.9,116.15,,,fee schedule,116.51% of cms physician fee schedule,164.83,48.48,,131.864,percent of total billed charges,48.48% of total billed charges,238,70,,190.4,percent of total billed charges,70% of total billed charges,238,70,,190.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,164.83,48.48,,131.864,percent of total billed charges,48.48% of total billed charges,306,90,,244.8,percent of total billed charges,90% of total billed charges,48.48,306,
CALCANEOUS 2 VIEWS,42000611,CDM,320,RC,73650,HCPCS,outpatient,,,315,189.00,TC,189,60,,151.2,percent of total billed charges,60% of total billed charges,151.2,48,,120.96,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,157.5,50,,126,percent of total billed charges,50% of total billed charges,220.5,70,,176.4,percent of total billed charges,70% of total billed charges,152.71,48.48,,122.168,percent of total billed charges,48.48% of total billed charges,30.09,116.15,,,fee schedule,116.51% of cms physician fee schedule,152.71,48.48,,122.168,percent of total billed charges,48.48% of total billed charges,220.5,70,,176.4,percent of total billed charges,70% of total billed charges,220.5,70,,176.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,152.71,48.48,,122.168,percent of total billed charges,48.48% of total billed charges,283.5,90,,226.8,percent of total billed charges,90% of total billed charges,48.48,283.5,
TOES 2 VIEWS RT,42000970,CDM,320,RC,73660,HCPCS,outpatient,,,328,196.80,TC,196.8,60,,157.44,percent of total billed charges,60% of total billed charges,157.44,48,,125.952,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,164,50,,131.2,percent of total billed charges,50% of total billed charges,229.6,70,,183.68,percent of total billed charges,70% of total billed charges,159.01,48.48,,127.208,percent of total billed charges,48.48% of total billed charges,30.63,116.15,,,fee schedule,116.51% of cms physician fee schedule,159.01,48.48,,127.208,percent of total billed charges,48.48% of total billed charges,229.6,70,,183.68,percent of total billed charges,70% of total billed charges,229.6,70,,183.68,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,159.01,48.48,,127.208,percent of total billed charges,48.48% of total billed charges,295.2,90,,236.16,percent of total billed charges,90% of total billed charges,48.48,295.2,
LUMBAR SPNE CMPLTE W/BEND  MIN 6 VIEW,42000480,CDM,320,RC,72114,HCPCS,outpatient,,,726,435.60,TC,435.6,60,,348.48,percent of total billed charges,60% of total billed charges,348.48,48,,278.784,percent of total billed charges,48% of total billed charges,109.7,100,,,fee schedule,100% of bcbs custom fee schedule,109.7,100,,,fee schedule,100% of bcbs custom fee schedule,121.77,111,,,fee schedule,111% of bcbs custom fee schedule,363,50,,290.4,percent of total billed charges,50% of total billed charges,508.2,70,,406.56,percent of total billed charges,70% of total billed charges,351.96,48.48,,281.568,percent of total billed charges,48.48% of total billed charges,64.07,116.15,,,fee schedule,116.51% of cms physician fee schedule,351.96,48.48,,281.568,percent of total billed charges,48.48% of total billed charges,508.2,70,,406.56,percent of total billed charges,70% of total billed charges,508.2,70,,406.56,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,351.96,48.48,,281.568,percent of total billed charges,48.48% of total billed charges,653.4,90,,522.72,percent of total billed charges,90% of total billed charges,48.48,653.4,
HUMERUS MIN 2 VIEW BIL,42000381,CDM,320,RC,73060,HCPCS,outpatient,,,504,302.40,TC,302.4,60,,241.92,percent of total billed charges,60% of total billed charges,241.92,48,,193.536,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,252,50,,201.6,percent of total billed charges,50% of total billed charges,352.8,70,,282.24,percent of total billed charges,70% of total billed charges,244.34,48.48,,195.472,percent of total billed charges,48.48% of total billed charges,33.49,116.15,,,fee schedule,116.51% of cms physician fee schedule,244.34,48.48,,195.472,percent of total billed charges,48.48% of total billed charges,352.8,70,,282.24,percent of total billed charges,70% of total billed charges,352.8,70,,282.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,244.34,48.48,,195.472,percent of total billed charges,48.48% of total billed charges,453.6,90,,362.88,percent of total billed charges,90% of total billed charges,48.48,453.6,
FOREARM 2VIEW BIL,42000346,CDM,320,RC,73090,HCPCS,outpatient,,,448,268.80,TC,268.8,60,,215.04,percent of total billed charges,60% of total billed charges,215.04,48,,172.032,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,224,50,,179.2,percent of total billed charges,50% of total billed charges,313.6,70,,250.88,percent of total billed charges,70% of total billed charges,217.19,48.48,,173.752,percent of total billed charges,48.48% of total billed charges,30.77,116.15,,,fee schedule,116.51% of cms physician fee schedule,217.19,48.48,,173.752,percent of total billed charges,48.48% of total billed charges,313.6,70,,250.88,percent of total billed charges,70% of total billed charges,313.6,70,,250.88,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,217.19,48.48,,173.752,percent of total billed charges,48.48% of total billed charges,403.2,90,,322.56,percent of total billed charges,90% of total billed charges,48.48,403.2,
FEMUR AP/LAT BIL,42000301,CDM,320,RC,73552,HCPCS,outpatient,,,566,339.60,TC,339.6,60,,271.68,percent of total billed charges,60% of total billed charges,271.68,48,,217.344,percent of total billed charges,48% of total billed charges,36.69,100,,,fee schedule,100% of bcbs custom fee schedule,36.69,100,,,fee schedule,100% of bcbs custom fee schedule,40.73,111,,,fee schedule,111% of bcbs custom fee schedule,283,50,,226.4,percent of total billed charges,50% of total billed charges,396.2,70,,316.96,percent of total billed charges,70% of total billed charges,274.4,48.48,,219.52,percent of total billed charges,48.48% of total billed charges,37.31,116.15,,,fee schedule,116.51% of cms physician fee schedule,274.4,48.48,,219.52,percent of total billed charges,48.48% of total billed charges,396.2,70,,316.96,percent of total billed charges,70% of total billed charges,396.2,70,,316.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,274.4,48.48,,219.52,percent of total billed charges,48.48% of total billed charges,509.4,90,,407.52,percent of total billed charges,90% of total billed charges,48.48,509.4,
TIB/FIB 2VIEW BIL,42000801,CDM,320,RC,73590,HCPCS,outpatient,,,498,298.80,TC,298.8,60,,239.04,percent of total billed charges,60% of total billed charges,239.04,48,,191.232,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,249,50,,199.2,percent of total billed charges,50% of total billed charges,348.6,70,,278.88,percent of total billed charges,70% of total billed charges,241.43,48.48,,193.144,percent of total billed charges,48.48% of total billed charges,33.15,116.15,,,fee schedule,116.51% of cms physician fee schedule,241.43,48.48,,193.144,percent of total billed charges,48.48% of total billed charges,348.6,70,,278.88,percent of total billed charges,70% of total billed charges,348.6,70,,278.88,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,241.43,48.48,,193.144,percent of total billed charges,48.48% of total billed charges,448.2,90,,358.56,percent of total billed charges,90% of total billed charges,48.48,448.2,
KNEE AP/LAT BILATERAL,42000431,CDM,320,RC,73560,HCPCS,outpatient,,,542,325.20,TC,325.2,60,,260.16,percent of total billed charges,60% of total billed charges,260.16,48,,208.128,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,271,50,,216.8,percent of total billed charges,50% of total billed charges,379.4,70,,303.52,percent of total billed charges,70% of total billed charges,262.76,48.48,,210.208,percent of total billed charges,48.48% of total billed charges,35.86,116.15,,,fee schedule,116.51% of cms physician fee schedule,262.76,48.48,,210.208,percent of total billed charges,48.48% of total billed charges,379.4,70,,303.52,percent of total billed charges,70% of total billed charges,379.4,70,,303.52,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,262.76,48.48,,210.208,percent of total billed charges,48.48% of total billed charges,487.8,90,,390.24,percent of total billed charges,90% of total billed charges,48.48,487.8,
CLAVICLE 2V bilat,,,320,RC,73040,HCPCS,outpatient,,,479,287.40,TC,287.4,60,,229.92,percent of total billed charges,60% of total billed charges,229.92,48,,183.936,percent of total billed charges,48% of total billed charges,308.57,100,,,fee schedule,100% of bcbs custom fee schedule,308.57,100,,,fee schedule,100% of bcbs custom fee schedule,342.51,111,,,fee schedule,111% of bcbs custom fee schedule,239.5,50,,191.6,percent of total billed charges,50% of total billed charges,335.3,70,,268.24,percent of total billed charges,70% of total billed charges,232.22,48.48,,185.776,percent of total billed charges,48.48% of total billed charges,136.78,116.15,,,fee schedule,116.51% of cms physician fee schedule,232.22,48.48,,185.776,percent of total billed charges,48.48% of total billed charges,335.3,70,,268.24,percent of total billed charges,70% of total billed charges,335.3,70,,268.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,232.22,48.48,,185.776,percent of total billed charges,48.48% of total billed charges,431.1,90,,344.88,percent of total billed charges,90% of total billed charges,48.48,431.1,
RIBS UNILAT W/ 1V CHEST 3+ VIEWS LT,42000681,CDM,320,RC,71101,HCPCS,outpatient,,,73.56,44.14,TC,44.14,60,,35.312,percent of total billed charges,60% of total billed charges,35.31,48,,28.248,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,36.78,50,,29.424,percent of total billed charges,50% of total billed charges,51.49,70,,41.192,percent of total billed charges,70% of total billed charges,35.66,48.48,,28.528,percent of total billed charges,48.48% of total billed charges,44.51,116.15,,,fee schedule,116.51% of cms physician fee schedule,35.66,48.48,,28.528,percent of total billed charges,48.48% of total billed charges,51.49,70,,41.192,percent of total billed charges,70% of total billed charges,51.49,70,,41.192,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,35.66,48.48,,28.528,percent of total billed charges,48.48% of total billed charges,66.2,90,,52.96,percent of total billed charges,90% of total billed charges,35.66,90,
RIBS UNILAT W/ 1V CHEST 3+ VIEWS RT,42000681,CDM,320,RC,71101,HCPCS,outpatient,,,73.56,44.14,TC,44.14,60,,35.312,percent of total billed charges,60% of total billed charges,35.31,48,,28.248,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,36.78,50,,29.424,percent of total billed charges,50% of total billed charges,51.49,70,,41.192,percent of total billed charges,70% of total billed charges,35.66,48.48,,28.528,percent of total billed charges,48.48% of total billed charges,44.51,116.15,,,fee schedule,116.51% of cms physician fee schedule,35.66,48.48,,28.528,percent of total billed charges,48.48% of total billed charges,51.49,70,,41.192,percent of total billed charges,70% of total billed charges,51.49,70,,41.192,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,35.66,48.48,,28.528,percent of total billed charges,48.48% of total billed charges,66.2,90,,52.96,percent of total billed charges,90% of total billed charges,35.66,90,
SCOLIOSIS SERIES 4-5 VIEWS,42001077,CDM,320,RC,72083,HCPCS,outpatient,,,165.31,99.19,TC,99.19,60,,79.352,percent of total billed charges,60% of total billed charges,79.35,48,,63.48,percent of total billed charges,48% of total billed charges,80.35,100,,,fee schedule,100% of bcbs custom fee schedule,80.35,100,,,fee schedule,100% of bcbs custom fee schedule,89.19,111,,,fee schedule,111% of bcbs custom fee schedule,82.66,50,,66.128,percent of total billed charges,50% of total billed charges,115.72,70,,92.576,percent of total billed charges,70% of total billed charges,80.14,48.48,,64.112,percent of total billed charges,48.48% of total billed charges,82.49,116.15,,,fee schedule,116.51% of cms physician fee schedule,80.14,48.48,,64.112,percent of total billed charges,48.48% of total billed charges,115.72,70,,92.576,percent of total billed charges,70% of total billed charges,115.72,70,,92.576,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,80.14,48.48,,64.112,percent of total billed charges,48.48% of total billed charges,148.78,90,,119.024,percent of total billed charges,90% of total billed charges,48.48,148.78,
ENTIRE SPINE 1 VIEW,42001075,CDM,320,RC,72081,HCPCS,outpatient,,,80.34,48.20,TC,48.2,60,,38.56,percent of total billed charges,60% of total billed charges,38.56,48,,30.848,percent of total billed charges,48% of total billed charges,40.73,100,,,fee schedule,100% of bcbs custom fee schedule,40.73,100,,,fee schedule,100% of bcbs custom fee schedule,45.21,111,,,fee schedule,111% of bcbs custom fee schedule,40.17,50,,32.136,percent of total billed charges,50% of total billed charges,56.24,70,,44.992,percent of total billed charges,70% of total billed charges,38.95,48.48,,31.16,percent of total billed charges,48.48% of total billed charges,44.8,116.15,,,fee schedule,116.51% of cms physician fee schedule,38.95,48.48,,31.16,percent of total billed charges,48.48% of total billed charges,56.24,70,,44.992,percent of total billed charges,70% of total billed charges,56.24,70,,44.992,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,38.95,48.48,,31.16,percent of total billed charges,48.48% of total billed charges,72.31,90,,57.848,percent of total billed charges,90% of total billed charges,38.95,90,
HIPS BILATERAL 3-4 VIEWS,42001070,CDM,320,RC,73522,HCPCS,outpatient,,,465,279.00,TC,279,60,,223.2,percent of total billed charges,60% of total billed charges,223.2,48,,178.56,percent of total billed charges,48% of total billed charges,53.93,100,,,fee schedule,100% of bcbs custom fee schedule,53.93,100,,,fee schedule,100% of bcbs custom fee schedule,59.86,111,,,fee schedule,111% of bcbs custom fee schedule,232.5,50,,186,percent of total billed charges,50% of total billed charges,325.5,70,,260.4,percent of total billed charges,70% of total billed charges,225.43,48.48,,180.344,percent of total billed charges,48.48% of total billed charges,56.46,116.15,,,fee schedule,116.51% of cms physician fee schedule,225.43,48.48,,180.344,percent of total billed charges,48.48% of total billed charges,325.5,70,,260.4,percent of total billed charges,70% of total billed charges,325.5,70,,260.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,225.43,48.48,,180.344,percent of total billed charges,48.48% of total billed charges,418.5,90,,334.8,percent of total billed charges,90% of total billed charges,48.48,418.5,
BONE AGE STUDY,42000105,CDM,320,RC,77072,HCPCS,outpatient,,,54,32.40,TC,32.4,60,,25.92,percent of total billed charges,60% of total billed charges,25.92,48,,20.736,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,27,50,,21.6,percent of total billed charges,50% of total billed charges,37.8,70,,30.24,percent of total billed charges,70% of total billed charges,26.18,48.48,,20.944,percent of total billed charges,48.48% of total billed charges,27.53,116.15,,,fee schedule,116.51% of cms physician fee schedule,26.18,48.48,,20.944,percent of total billed charges,48.48% of total billed charges,37.8,70,,30.24,percent of total billed charges,70% of total billed charges,37.8,70,,30.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,26.18,48.48,,20.944,percent of total billed charges,48.48% of total billed charges,48.6,90,,38.88,percent of total billed charges,90% of total billed charges,26.18,90,
SHUNT SERIES,,,320,RC,75809,HCPCS,outpatient,,,227.25,136.35,TC,136.35,60,,109.08,percent of total billed charges,60% of total billed charges,109.08,48,,87.264,percent of total billed charges,48% of total billed charges,150.01,100,,,fee schedule,100% of bcbs custom fee schedule,150.01,100,,,fee schedule,100% of bcbs custom fee schedule,166.51,111,,,fee schedule,111% of bcbs custom fee schedule,113.63,50,,90.904,percent of total billed charges,50% of total billed charges,159.08,70,,127.264,percent of total billed charges,70% of total billed charges,110.17,48.48,,88.136,percent of total billed charges,48.48% of total billed charges,85.64,116.15,,,fee schedule,116.51% of cms physician fee schedule,110.17,48.48,,88.136,percent of total billed charges,48.48% of total billed charges,159.08,70,,127.264,percent of total billed charges,70% of total billed charges,159.08,70,,127.264,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,110.17,48.48,,88.136,percent of total billed charges,48.48% of total billed charges,204.53,90,,163.624,percent of total billed charges,90% of total billed charges,48.48,204.53,
SI JOINTS 3/> VIEWS,42000690,CDM,320,RC,72202,HCPCS,outpatient,,,314.25,188.55,TC,188.55,60,,150.84,percent of total billed charges,60% of total billed charges,150.84,48,,120.672,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,157.13,50,,125.704,percent of total billed charges,50% of total billed charges,219.98,70,,175.984,percent of total billed charges,70% of total billed charges,152.35,48.48,,121.88,percent of total billed charges,48.48% of total billed charges,41.27,116.15,,,fee schedule,116.51% of cms physician fee schedule,152.35,48.48,,121.88,percent of total billed charges,48.48% of total billed charges,219.98,70,,175.984,percent of total billed charges,70% of total billed charges,219.98,70,,175.984,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,152.35,48.48,,121.88,percent of total billed charges,48.48% of total billed charges,282.83,90,,226.264,percent of total billed charges,90% of total billed charges,48.48,282.83,
CALCANEOUS 2VW BILATERAL,42000611,CDM,320,RC,73650,HCPCS,outpatient,,,473,283.80,TC,283.8,60,,227.04,percent of total billed charges,60% of total billed charges,227.04,48,,181.632,percent of total billed charges,48% of total billed charges,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,64.47,100,,,fee schedule,100% of bcbs custom fee schedule,71.56,111,,,fee schedule,111% of bcbs custom fee schedule,236.5,50,,189.2,percent of total billed charges,50% of total billed charges,331.1,70,,264.88,percent of total billed charges,70% of total billed charges,229.31,48.48,,183.448,percent of total billed charges,48.48% of total billed charges,30.09,116.15,,,fee schedule,116.51% of cms physician fee schedule,229.31,48.48,,183.448,percent of total billed charges,48.48% of total billed charges,331.1,70,,264.88,percent of total billed charges,70% of total billed charges,331.1,70,,264.88,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,229.31,48.48,,183.448,percent of total billed charges,48.48% of total billed charges,425.7,90,,340.56,percent of total billed charges,90% of total billed charges,48.48,425.7,
SCREENING MAMMOGRAPHY BILATERAL,42001029,CDM,403,RC,77067,HCPCS,outpatient,,,260,156.00,TC,156,60,,124.8,percent of total billed charges,60% of total billed charges,124.8,48,,99.84,percent of total billed charges,48% of total billed charges,123.27,100,,,fee schedule,100% of bcbs custom fee schedule,123.27,100,,,fee schedule,100% of bcbs custom fee schedule,136.83,111,,,fee schedule,111% of bcbs custom fee schedule,130,50,,104,percent of total billed charges,50% of total billed charges,182,70,,145.6,percent of total billed charges,70% of total billed charges,126.05,48.48,,100.84,percent of total billed charges,48.48% of total billed charges,134.21,116.15,,,fee schedule,116.51% of cms physician fee schedule,126.05,48.48,,100.84,percent of total billed charges,48.48% of total billed charges,182,70,,145.6,percent of total billed charges,70% of total billed charges,182,70,,145.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,126.05,48.48,,100.84,percent of total billed charges,48.48% of total billed charges,234,90,,187.2,percent of total billed charges,90% of total billed charges,48.48,234,
BREAST TOMOSYNTHESIS,42008016,CDM,403,RC,77063,HCPCS,outpatient,,,50,30.00,,30,60,,24,percent of total billed charges,60% of total billed charges,24,48,,19.2,percent of total billed charges,48% of total billed charges,16.19,100,,,fee schedule,100% of bcbs custom fee schedule,16.19,100,,,fee schedule,100% of bcbs custom fee schedule,17.97,111,,,fee schedule,111% of bcbs custom fee schedule,25,50,,20,percent of total billed charges,50% of total billed charges,35,70,,28,percent of total billed charges,70% of total billed charges,24.24,48.48,,19.392,percent of total billed charges,48.48% of total billed charges,56.02,116.15,,,fee schedule,116.51% of cms physician fee schedule,24.24,48.48,,19.392,percent of total billed charges,48.48% of total billed charges,35,70,,28,percent of total billed charges,70% of total billed charges,35,70,,28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,24.24,48.48,,19.392,percent of total billed charges,48.48% of total billed charges,45,90,,36,percent of total billed charges,90% of total billed charges,24.24,90,
SCREENING MAMMOGRAPHY LEFT,42001029,CDM,403,RC,77067,HCPCS,outpatient,,,130,78.00,52,78,60,,62.4,percent of total billed charges,60% of total billed charges,62.4,48,,49.92,percent of total billed charges,48% of total billed charges,123.27,100,,,fee schedule,100% of bcbs custom fee schedule,123.27,100,,,fee schedule,100% of bcbs custom fee schedule,136.83,111,,,fee schedule,111% of bcbs custom fee schedule,65,50,,52,percent of total billed charges,50% of total billed charges,91,70,,72.8,percent of total billed charges,70% of total billed charges,63.02,48.48,,50.416,percent of total billed charges,48.48% of total billed charges,134.21,116.15,,,fee schedule,116.51% of cms physician fee schedule,63.02,48.48,,50.416,percent of total billed charges,48.48% of total billed charges,91,70,,72.8,percent of total billed charges,70% of total billed charges,91,70,,72.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,63.02,48.48,,50.416,percent of total billed charges,48.48% of total billed charges,117,90,,93.6,percent of total billed charges,90% of total billed charges,48.48,117,
SCREENING MAMMOGRAPHY RIGHT,42001029,CDM,403,RC,77067,HCPCS,outpatient,,,130,78.00,52,78,60,,62.4,percent of total billed charges,60% of total billed charges,62.4,48,,49.92,percent of total billed charges,48% of total billed charges,123.27,100,,,fee schedule,100% of bcbs custom fee schedule,123.27,100,,,fee schedule,100% of bcbs custom fee schedule,136.83,111,,,fee schedule,111% of bcbs custom fee schedule,65,50,,52,percent of total billed charges,50% of total billed charges,91,70,,72.8,percent of total billed charges,70% of total billed charges,63.02,48.48,,50.416,percent of total billed charges,48.48% of total billed charges,134.21,116.15,,,fee schedule,116.51% of cms physician fee schedule,63.02,48.48,,50.416,percent of total billed charges,48.48% of total billed charges,91,70,,72.8,percent of total billed charges,70% of total billed charges,91,70,,72.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,63.02,48.48,,50.416,percent of total billed charges,48.48% of total billed charges,117,90,,93.6,percent of total billed charges,90% of total billed charges,48.48,117,
BARIUM SWALLOW,42000275,CDM,320,RC,74220,HCPCS,outpatient,,,2062.6,1237.56,TC,1237.56,60,,990.048,percent of total billed charges,60% of total billed charges,990.05,48,,792.04,percent of total billed charges,48% of total billed charges,129.81,100,,,fee schedule,100% of bcbs custom fee schedule,129.81,100,,,fee schedule,100% of bcbs custom fee schedule,144.09,111,,,fee schedule,111% of bcbs custom fee schedule,1031.3,50,,825.04,percent of total billed charges,50% of total billed charges,1443.82,70,,1155.056,percent of total billed charges,70% of total billed charges,999.95,48.48,,799.96,percent of total billed charges,48.48% of total billed charges,102.19,116.15,,,fee schedule,116.51% of cms physician fee schedule,999.95,48.48,,799.96,percent of total billed charges,48.48% of total billed charges,1443.82,70,,1155.056,percent of total billed charges,70% of total billed charges,1443.82,70,,1155.056,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,999.95,48.48,,799.96,percent of total billed charges,48.48% of total billed charges,1856.34,90,,1485.072,percent of total billed charges,90% of total billed charges,48.48,1856.34,
COLONOSCOPY,,,750,RC,45378,HCPCS,outpatient,,,1427.5,856.50,,535,100,,,fee schedule,100% of asc tier groupings rate,685.2,48,,548.16,percent of total billed charges,48% of total billed charges,1391.96,100,,,fee schedule,100% of bcbs custom fee schedule,1391.96,100,,,fee schedule,100% of bcbs custom fee schedule,1545.08,111,,,fee schedule,111% of bcbs custom fee schedule,713.75,50,,571,percent of total billed charges,50% of total billed charges,999.25,70,,799.4,percent of total billed charges,70% of total billed charges,692.05,48.48,,553.64,percent of total billed charges,48.48% of total billed charges,204.56,116.15,,,fee schedule,116.51% of cms physician fee schedule,692.05,48.48,,553.64,percent of total billed charges,48.48% of total billed charges,999.25,70,,799.4,percent of total billed charges,70% of total billed charges,999.25,70,,799.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,692.05,48.48,,553.64,percent of total billed charges,48.48% of total billed charges,1284.75,90,,1027.8,percent of total billed charges,90% of total billed charges,48.48,1284.75,
MRI LOWER EXT W/O (nlmc),42004201,CDM,610,RC,73718,HCPCS,outpatient,,,4063.21,2437.93,LT,2437.93,60,,1950.344,percent of total billed charges,60% of total billed charges,1950.34,48,,1560.272,percent of total billed charges,48% of total billed charges,707.65,100,,,fee schedule,100% of bcbs custom fee schedule,707.65,100,,,fee schedule,100% of bcbs custom fee schedule,785.49,111,,,fee schedule,111% of bcbs custom fee schedule,600,100,,,case rate,pays based on per visit rate,2844.25,70,,2275.4,percent of total billed charges,70% of total billed charges,1969.84,48.48,,1575.872,percent of total billed charges,48.48% of total billed charges,240.76,116.15,,,fee schedule,116.51% of cms physician fee schedule,1969.84,48.48,,1575.872,percent of total billed charges,48.48% of total billed charges,2844.25,70,,2275.4,percent of total billed charges,70% of total billed charges,2844.25,70,,2275.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,1969.84,48.48,,1575.872,percent of total billed charges,48.48% of total billed charges,3656.89,90,,2925.512,percent of total billed charges,90% of total billed charges,48.48,3656.89,
DPLX SCAN EXTRCRA ART BIL,42001048,CDM,921,RC,93880,HCPCS,outpatient,,,2382,1429.20,TC,1429.2,60,,1143.36,percent of total billed charges,60% of total billed charges,1143.36,48,,914.688,percent of total billed charges,48% of total billed charges,334.45,100,,,fee schedule,100% of bcbs custom fee schedule,334.45,100,,,fee schedule,100% of bcbs custom fee schedule,371.24,111,,,fee schedule,111% of bcbs custom fee schedule,1191,50,,952.8,percent of total billed charges,50% of total billed charges,1667.4,70,,1333.92,percent of total billed charges,70% of total billed charges,1154.79,48.48,,923.832,percent of total billed charges,48.48% of total billed charges,197.92,116.15,,,fee schedule,116.51% of cms physician fee schedule,1154.79,48.48,,923.832,percent of total billed charges,48.48% of total billed charges,1667.4,70,,1333.92,percent of total billed charges,70% of total billed charges,1667.4,70,,1333.92,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,1154.79,48.48,,923.832,percent of total billed charges,48.48% of total billed charges,2143.8,90,,1715.04,percent of total billed charges,90% of total billed charges,48.48,2143.8,
"CINE/VID X-RAY, THROAT",,,320,RC,74230,HCPCS,outpatient,,,1486,891.60,TC,891.6,60,,713.28,percent of total billed charges,60% of total billed charges,713.28,48,,570.624,percent of total billed charges,48% of total billed charges,129.81,100,,,fee schedule,100% of bcbs custom fee schedule,129.81,100,,,fee schedule,100% of bcbs custom fee schedule,144.09,111,,,fee schedule,111% of bcbs custom fee schedule,743,50,,594.4,percent of total billed charges,50% of total billed charges,1040.2,70,,832.16,percent of total billed charges,70% of total billed charges,720.41,48.48,,576.328,percent of total billed charges,48.48% of total billed charges,129.62,116.15,,,fee schedule,116.51% of cms physician fee schedule,720.41,48.48,,576.328,percent of total billed charges,48.48% of total billed charges,1040.2,70,,832.16,percent of total billed charges,70% of total billed charges,1040.2,70,,832.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,720.41,48.48,,576.328,percent of total billed charges,48.48% of total billed charges,1337.4,90,,1069.92,percent of total billed charges,90% of total billed charges,48.48,1337.4,
"BONE IMAGING, WHOLE BODY",42107687,CDM,341,RC,78306,HCPCS,outpatient,,,3046,1827.60,TC,1827.6,60,,1462.08,percent of total billed charges,60% of total billed charges,1462.08,48,,1169.664,percent of total billed charges,48% of total billed charges,352.7,100,,,fee schedule,100% of bcbs custom fee schedule,352.7,100,,,fee schedule,100% of bcbs custom fee schedule,391.5,111,,,fee schedule,111% of bcbs custom fee schedule,1523,50,,1218.4,percent of total billed charges,50% of total billed charges,2132.2,70,,1705.76,percent of total billed charges,70% of total billed charges,1476.7,48.48,,1181.36,percent of total billed charges,48.48% of total billed charges,278.61,116.15,,,fee schedule,116.51% of cms physician fee schedule,1476.7,48.48,,1181.36,percent of total billed charges,48.48% of total billed charges,2132.2,70,,1705.76,percent of total billed charges,70% of total billed charges,2132.2,70,,1705.76,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,1476.7,48.48,,1181.36,percent of total billed charges,48.48% of total billed charges,2741.4,90,,2193.12,percent of total billed charges,90% of total billed charges,48.48,2741.4,
XR UPPER GI DELAY,,,320,RC,74240,HCPCS,outpatient,,,1374,824.40,TC,824.4,60,,659.52,percent of total billed charges,60% of total billed charges,659.52,48,,527.616,percent of total billed charges,48% of total billed charges,129.81,100,,,fee schedule,100% of bcbs custom fee schedule,129.81,100,,,fee schedule,100% of bcbs custom fee schedule,144.09,111,,,fee schedule,111% of bcbs custom fee schedule,687,50,,549.6,percent of total billed charges,50% of total billed charges,961.8,70,,769.44,percent of total billed charges,70% of total billed charges,666.12,48.48,,532.896,percent of total billed charges,48.48% of total billed charges,128.98,116.15,,,fee schedule,116.51% of cms physician fee schedule,666.12,48.48,,532.896,percent of total billed charges,48.48% of total billed charges,961.8,70,,769.44,percent of total billed charges,70% of total billed charges,961.8,70,,769.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,666.12,48.48,,532.896,percent of total billed charges,48.48% of total billed charges,1236.6,90,,989.28,percent of total billed charges,90% of total billed charges,48.48,1236.6,
CT HEAD/ BRAIN WO CNTRST,42003110,CDM,350,RC,70450,HCPCS,outpatient,,,1349,809.40,TC,219,100,,,fee schedule,100% of aetna fee schedule,647.52,48,,518.016,percent of total billed charges,48% of total billed charges,354.43,100,,,fee schedule,100% of bcbs custom fee schedule,354.43,100,,,fee schedule,100% of bcbs custom fee schedule,393.42,111,,,fee schedule,111% of bcbs custom fee schedule,450,100,,,case rate,pays based on per visit rate,944.3,70,,755.44,percent of total billed charges,70% of total billed charges,654,48.48,,523.2,percent of total billed charges,48.48% of total billed charges,115,116.15,,,fee schedule,116.51% of cms physician fee schedule,654,48.48,,523.2,percent of total billed charges,48.48% of total billed charges,944.3,70,,755.44,percent of total billed charges,70% of total billed charges,944.3,70,,755.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,654,48.48,,523.2,percent of total billed charges,48.48% of total billed charges,1214.1,90,,971.28,percent of total billed charges,90% of total billed charges,48.48,1214.1,
CT HEAD/ BRAIN W CNTRST,42003120,CDM,350,RC,70460,HCPCS,outpatient,,,1387.5,832.50,TC,832.5,60,,666,percent of total billed charges,60% of total billed charges,666,48,,532.8,percent of total billed charges,48% of total billed charges,425.03,100,,,fee schedule,100% of bcbs custom fee schedule,425.03,100,,,fee schedule,100% of bcbs custom fee schedule,471.78,111,,,fee schedule,111% of bcbs custom fee schedule,450,100,,,case rate,pays based on per visit rate,971.25,70,,777,percent of total billed charges,70% of total billed charges,672.66,48.48,,538.128,percent of total billed charges,48.48% of total billed charges,160.58,116.15,,,fee schedule,116.51% of cms physician fee schedule,672.66,48.48,,538.128,percent of total billed charges,48.48% of total billed charges,971.25,70,,777,percent of total billed charges,70% of total billed charges,971.25,70,,777,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,672.66,48.48,,538.128,percent of total billed charges,48.48% of total billed charges,1248.75,90,,999,percent of total billed charges,90% of total billed charges,48.48,1248.75,
CT HEAD/BRAIN W/WO CNTRS,42003130,CDM,350,RC,70470,HCPCS,outpatient,,,1525,915.00,TC,915,60,,732,percent of total billed charges,60% of total billed charges,732,48,,585.6,percent of total billed charges,48% of total billed charges,530.5,100,,,fee schedule,100% of bcbs custom fee schedule,530.5,100,,,fee schedule,100% of bcbs custom fee schedule,588.86,111,,,fee schedule,111% of bcbs custom fee schedule,450,100,,,case rate,pays based on per visit rate,1067.5,70,,854,percent of total billed charges,70% of total billed charges,739.32,48.48,,591.456,percent of total billed charges,48.48% of total billed charges,187.87,116.15,,,fee schedule,116.51% of cms physician fee schedule,739.32,48.48,,591.456,percent of total billed charges,48.48% of total billed charges,1067.5,70,,854,percent of total billed charges,70% of total billed charges,1067.5,70,,854,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,739.32,48.48,,591.456,percent of total billed charges,48.48% of total billed charges,1372.5,90,,1098,percent of total billed charges,90% of total billed charges,48.48,1372.5,
CT ORB/SEL/PF/EAR W/O CNT,42003160,CDM,350,RC,70480,HCPCS,outpatient,,,1137.5,682.50,TC,682.5,60,,546,percent of total billed charges,60% of total billed charges,546,48,,436.8,percent of total billed charges,48% of total billed charges,354.43,100,,,fee schedule,100% of bcbs custom fee schedule,354.43,100,,,fee schedule,100% of bcbs custom fee schedule,393.42,111,,,fee schedule,111% of bcbs custom fee schedule,450,100,,,case rate,pays based on per visit rate,796.25,70,,637,percent of total billed charges,70% of total billed charges,551.46,48.48,,441.168,percent of total billed charges,48.48% of total billed charges,172.68,116.15,,,fee schedule,116.51% of cms physician fee schedule,551.46,48.48,,441.168,percent of total billed charges,48.48% of total billed charges,796.25,70,,637,percent of total billed charges,70% of total billed charges,796.25,70,,637,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,551.46,48.48,,441.168,percent of total billed charges,48.48% of total billed charges,1023.75,90,,819,percent of total billed charges,90% of total billed charges,48.48,1023.75,
CT ORB/SEL/PF/EAR W CNTRS,42003150,CDM,350,RC,70481,HCPCS,outpatient,,,1275,765.00,TC,765,60,,612,percent of total billed charges,60% of total billed charges,612,48,,489.6,percent of total billed charges,48% of total billed charges,425.03,100,,,fee schedule,100% of bcbs custom fee schedule,425.03,100,,,fee schedule,100% of bcbs custom fee schedule,471.78,111,,,fee schedule,111% of bcbs custom fee schedule,450,100,,,case rate,pays based on per visit rate,892.5,70,,714,percent of total billed charges,70% of total billed charges,618.12,48.48,,494.496,percent of total billed charges,48.48% of total billed charges,194.55,116.15,,,fee schedule,116.51% of cms physician fee schedule,618.12,48.48,,494.496,percent of total billed charges,48.48% of total billed charges,892.5,70,,714,percent of total billed charges,70% of total billed charges,892.5,70,,714,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,618.12,48.48,,494.496,percent of total billed charges,48.48% of total billed charges,1147.5,90,,918,percent of total billed charges,90% of total billed charges,48.48,1147.5,
CT ORB/SEL/PF/EAR W/WO CNTRS,42003140,CDM,350,RC,70482,HCPCS,outpatient,,,2718,1630.80,TC,1630.8,60,,1304.64,percent of total billed charges,60% of total billed charges,1304.64,48,,1043.712,percent of total billed charges,48% of total billed charges,530.5,100,,,fee schedule,100% of bcbs custom fee schedule,530.5,100,,,fee schedule,100% of bcbs custom fee schedule,588.86,111,,,fee schedule,111% of bcbs custom fee schedule,450,100,,,case rate,pays based on per visit rate,1902.6,70,,1522.08,percent of total billed charges,70% of total billed charges,1317.69,48.48,,1054.152,percent of total billed charges,48.48% of total billed charges,226.83,116.15,,,fee schedule,116.51% of cms physician fee schedule,1317.69,48.48,,1054.152,percent of total billed charges,48.48% of total billed charges,1902.6,70,,1522.08,percent of total billed charges,70% of total billed charges,1902.6,70,,1522.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,1317.69,48.48,,1054.152,percent of total billed charges,48.48% of total billed charges,2446.2,90,,1956.96,percent of total billed charges,90% of total billed charges,48.48,2446.2,
CT MAXIOFACIAL W/O CNTRST,42003240,CDM,350,RC,70486,HCPCS,outpatient,,,1631,978.60,TC,234,100,,,fee schedule,100% of aetna fee schedule,782.88,48,,626.304,percent of total billed charges,48% of total billed charges,354.43,100,,,fee schedule,100% of bcbs custom fee schedule,354.43,100,,,fee schedule,100% of bcbs custom fee schedule,393.42,111,,,fee schedule,111% of bcbs custom fee schedule,450,100,,,case rate,pays based on per visit rate,1141.7,70,,913.36,percent of total billed charges,70% of total billed charges,790.71,48.48,,632.568,percent of total billed charges,48.48% of total billed charges,138.03,116.15,,,fee schedule,116.51% of cms physician fee schedule,790.71,48.48,,632.568,percent of total billed charges,48.48% of total billed charges,1141.7,70,,913.36,percent of total billed charges,70% of total billed charges,1141.7,70,,913.36,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,790.71,48.48,,632.568,percent of total billed charges,48.48% of total billed charges,1467.9,90,,1174.32,percent of total billed charges,90% of total billed charges,48.48,1467.9,
CT MAXILLOFACIAL W CNTRS,42003230,CDM,350,RC,70487,HCPCS,outpatient,,,1850,1110.00,TC,1110,60,,888,percent of total billed charges,60% of total billed charges,888,48,,710.4,percent of total billed charges,48% of total billed charges,425.03,100,,,fee schedule,100% of bcbs custom fee schedule,425.03,100,,,fee schedule,100% of bcbs custom fee schedule,471.78,111,,,fee schedule,111% of bcbs custom fee schedule,450,100,,,case rate,pays based on per visit rate,1295,70,,1036,percent of total billed charges,70% of total billed charges,896.88,48.48,,717.504,percent of total billed charges,48.48% of total billed charges,164.75,116.15,,,fee schedule,116.51% of cms physician fee schedule,896.88,48.48,,717.504,percent of total billed charges,48.48% of total billed charges,1295,70,,1036,percent of total billed charges,70% of total billed charges,1295,70,,1036,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,896.88,48.48,,717.504,percent of total billed charges,48.48% of total billed charges,1665,90,,1332,percent of total billed charges,90% of total billed charges,48.48,1665,
CT MAXILLOFACIAL W/WO CNTRST,42003250,CDM,350,RC,70488,HCPCS,outpatient,,,2390,1434.00,TC,1434,60,,1147.2,percent of total billed charges,60% of total billed charges,1147.2,48,,917.76,percent of total billed charges,48% of total billed charges,530.5,100,,,fee schedule,100% of bcbs custom fee schedule,530.5,100,,,fee schedule,100% of bcbs custom fee schedule,588.86,111,,,fee schedule,111% of bcbs custom fee schedule,450,100,,,case rate,pays based on per visit rate,1673,70,,1338.4,percent of total billed charges,70% of total billed charges,1158.67,48.48,,926.936,percent of total billed charges,48.48% of total billed charges,199.06,116.15,,,fee schedule,116.51% of cms physician fee schedule,1158.67,48.48,,926.936,percent of total billed charges,48.48% of total billed charges,1673,70,,1338.4,percent of total billed charges,70% of total billed charges,1673,70,,1338.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,1158.67,48.48,,926.936,percent of total billed charges,48.48% of total billed charges,2151,90,,1720.8,percent of total billed charges,90% of total billed charges,48.48,2151,
CT SFT TISSUE NCK W/O CNT,42003350,CDM,350,RC,70490,HCPCS,outpatient,,,1200,720.00,TC,720,60,,576,percent of total billed charges,60% of total billed charges,576,48,,460.8,percent of total billed charges,48% of total billed charges,354.43,100,,,fee schedule,100% of bcbs custom fee schedule,354.43,100,,,fee schedule,100% of bcbs custom fee schedule,393.42,111,,,fee schedule,111% of bcbs custom fee schedule,450,100,,,case rate,pays based on per visit rate,840,70,,672,percent of total billed charges,70% of total billed charges,581.76,48.48,,465.408,percent of total billed charges,48.48% of total billed charges,163.1,116.15,,,fee schedule,116.51% of cms physician fee schedule,581.76,48.48,,465.408,percent of total billed charges,48.48% of total billed charges,840,70,,672,percent of total billed charges,70% of total billed charges,840,70,,672,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,581.76,48.48,,465.408,percent of total billed charges,48.48% of total billed charges,1080,90,,864,percent of total billed charges,90% of total billed charges,48.48,1080,
CT SFT TISSUE NCK W CNTRS,42003340,CDM,350,RC,70491,HCPCS,outpatient,,,1500,900.00,TC,900,60,,720,percent of total billed charges,60% of total billed charges,720,48,,576,percent of total billed charges,48% of total billed charges,425.03,100,,,fee schedule,100% of bcbs custom fee schedule,425.03,100,,,fee schedule,100% of bcbs custom fee schedule,471.78,111,,,fee schedule,111% of bcbs custom fee schedule,450,100,,,case rate,pays based on per visit rate,1050,70,,840,percent of total billed charges,70% of total billed charges,727.2,48.48,,581.76,percent of total billed charges,48.48% of total billed charges,199.58,116.15,,,fee schedule,116.51% of cms physician fee schedule,727.2,48.48,,581.76,percent of total billed charges,48.48% of total billed charges,1050,70,,840,percent of total billed charges,70% of total billed charges,1050,70,,840,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,727.2,48.48,,581.76,percent of total billed charges,48.48% of total billed charges,1350,90,,1080,percent of total billed charges,90% of total billed charges,48.48,1350,
CT NECK SOFT TISS WO/W CNTR,42003330,CDM,350,RC,70492,HCPCS,outpatient,,,2249,1349.40,TC,1349.4,60,,1079.52,percent of total billed charges,60% of total billed charges,1079.52,48,,863.616,percent of total billed charges,48% of total billed charges,530.5,100,,,fee schedule,100% of bcbs custom fee schedule,530.5,100,,,fee schedule,100% of bcbs custom fee schedule,588.86,111,,,fee schedule,111% of bcbs custom fee schedule,450,100,,,case rate,pays based on per visit rate,1574.3,70,,1259.44,percent of total billed charges,70% of total billed charges,1090.32,48.48,,872.256,percent of total billed charges,48.48% of total billed charges,239.11,116.15,,,fee schedule,116.51% of cms physician fee schedule,1090.32,48.48,,872.256,percent of total billed charges,48.48% of total billed charges,1574.3,70,,1259.44,percent of total billed charges,70% of total billed charges,1574.3,70,,1259.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,1090.32,48.48,,872.256,percent of total billed charges,48.48% of total billed charges,2024.1,90,,1619.28,percent of total billed charges,90% of total billed charges,48.48,2024.1,
CT THORAX W/O CONTRAST,42003100,CDM,350,RC,71250,HCPCS,outpatient,,,2100,1260.00,TC,1260,60,,1008,percent of total billed charges,60% of total billed charges,1008,48,,806.4,percent of total billed charges,48% of total billed charges,381.19,100,,,fee schedule,100% of bcbs custom fee schedule,381.19,100,,,fee schedule,100% of bcbs custom fee schedule,423.12,111,,,fee schedule,111% of bcbs custom fee schedule,450,100,,,case rate,pays based on per visit rate,1470,70,,1176,percent of total billed charges,70% of total billed charges,1018.08,48.48,,814.464,percent of total billed charges,48.48% of total billed charges,144.42,116.15,,,fee schedule,116.51% of cms physician fee schedule,1018.08,48.48,,814.464,percent of total billed charges,48.48% of total billed charges,1470,70,,1176,percent of total billed charges,70% of total billed charges,1470,70,,1176,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,1018.08,48.48,,814.464,percent of total billed charges,48.48% of total billed charges,1890,90,,1512,percent of total billed charges,90% of total billed charges,48.48,1890,
CT THORAX W CONTRAST,42003090,CDM,350,RC,71260,HCPCS,outpatient,,,2673,1603.80,TC,1603.8,60,,1283.04,percent of total billed charges,60% of total billed charges,1283.04,48,,1026.432,percent of total billed charges,48% of total billed charges,517.63,100,,,fee schedule,100% of bcbs custom fee schedule,517.63,100,,,fee schedule,100% of bcbs custom fee schedule,574.57,111,,,fee schedule,111% of bcbs custom fee schedule,450,100,,,case rate,pays based on per visit rate,1871.1,70,,1496.88,percent of total billed charges,70% of total billed charges,1295.87,48.48,,1036.696,percent of total billed charges,48.48% of total billed charges,180.47,116.15,,,fee schedule,116.51% of cms physician fee schedule,1295.87,48.48,,1036.696,percent of total billed charges,48.48% of total billed charges,1871.1,70,,1496.88,percent of total billed charges,70% of total billed charges,1871.1,70,,1496.88,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,1295.87,48.48,,1036.696,percent of total billed charges,48.48% of total billed charges,2405.7,90,,1924.56,percent of total billed charges,90% of total billed charges,48.48,2405.7,
CT THORAX W/O & W CONTRAS,42003080,CDM,350,RC,71270,HCPCS,outpatient,,,3204,1922.40,TC,1922.4,60,,1537.92,percent of total billed charges,60% of total billed charges,1537.92,48,,1230.336,percent of total billed charges,48% of total billed charges,615.7,100,,,fee schedule,100% of bcbs custom fee schedule,615.7,100,,,fee schedule,100% of bcbs custom fee schedule,683.43,111,,,fee schedule,111% of bcbs custom fee schedule,450,100,,,case rate,pays based on per visit rate,2242.8,70,,1794.24,percent of total billed charges,70% of total billed charges,1553.3,48.48,,1242.64,percent of total billed charges,48.48% of total billed charges,211.38,116.15,,,fee schedule,116.51% of cms physician fee schedule,1553.3,48.48,,1242.64,percent of total billed charges,48.48% of total billed charges,2242.8,70,,1794.24,percent of total billed charges,70% of total billed charges,2242.8,70,,1794.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,1553.3,48.48,,1242.64,percent of total billed charges,48.48% of total billed charges,2883.6,90,,2306.88,percent of total billed charges,90% of total billed charges,48.48,2883.6,
CT CERVICAL SPINE W/O CNTRS,42003070,CDM,350,RC,72125,HCPCS,outpatient,,,1325,795.00,TC,795,60,,636,percent of total billed charges,60% of total billed charges,636,48,,508.8,percent of total billed charges,48% of total billed charges,381.19,100,,,fee schedule,100% of bcbs custom fee schedule,381.19,100,,,fee schedule,100% of bcbs custom fee schedule,423.12,111,,,fee schedule,111% of bcbs custom fee schedule,450,100,,,case rate,pays based on per visit rate,927.5,70,,742,percent of total billed charges,70% of total billed charges,642.36,48.48,,513.888,percent of total billed charges,48.48% of total billed charges,140.89,116.15,,,fee schedule,116.51% of cms physician fee schedule,642.36,48.48,,513.888,percent of total billed charges,48.48% of total billed charges,927.5,70,,742,percent of total billed charges,70% of total billed charges,927.5,70,,742,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,642.36,48.48,,513.888,percent of total billed charges,48.48% of total billed charges,1192.5,90,,954,percent of total billed charges,90% of total billed charges,48.48,1192.5,
CT CERVICAL SPINE W CONTRAST,42003060,CDM,350,RC,72126,HCPCS,outpatient,,,1462,877.20,TC,877.2,60,,701.76,percent of total billed charges,60% of total billed charges,701.76,48,,561.408,percent of total billed charges,48% of total billed charges,517.63,100,,,fee schedule,100% of bcbs custom fee schedule,517.63,100,,,fee schedule,100% of bcbs custom fee schedule,574.57,111,,,fee schedule,111% of bcbs custom fee schedule,450,100,,,case rate,pays based on per visit rate,1023.4,70,,818.72,percent of total billed charges,70% of total billed charges,708.78,48.48,,567.024,percent of total billed charges,48.48% of total billed charges,182.45,116.15,,,fee schedule,116.51% of cms physician fee schedule,708.78,48.48,,567.024,percent of total billed charges,48.48% of total billed charges,1023.4,70,,818.72,percent of total billed charges,70% of total billed charges,1023.4,70,,818.72,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,708.78,48.48,,567.024,percent of total billed charges,48.48% of total billed charges,1315.8,90,,1052.64,percent of total billed charges,90% of total billed charges,48.48,1315.8,
CT CERVICAL SPINE W/WO CONTRAST,42003050,CDM,350,RC,72127,HCPCS,outpatient,,,2150,1290.00,TC,1290,60,,1032,percent of total billed charges,60% of total billed charges,1032,48,,825.6,percent of total billed charges,48% of total billed charges,615.7,100,,,fee schedule,100% of bcbs custom fee schedule,615.7,100,,,fee schedule,100% of bcbs custom fee schedule,683.43,111,,,fee schedule,111% of bcbs custom fee schedule,450,100,,,case rate,pays based on per visit rate,1505,70,,1204,percent of total billed charges,70% of total billed charges,1042.32,48.48,,833.856,percent of total billed charges,48.48% of total billed charges,212.94,116.15,,,fee schedule,116.51% of cms physician fee schedule,1042.32,48.48,,833.856,percent of total billed charges,48.48% of total billed charges,1505,70,,1204,percent of total billed charges,70% of total billed charges,1505,70,,1204,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,1042.32,48.48,,833.856,percent of total billed charges,48.48% of total billed charges,1935,90,,1548,percent of total billed charges,90% of total billed charges,48.48,1935,
CT THORACIC SPINE W/O CNT,42003380,CDM,350,RC,72128,HCPCS,outpatient,,,1325,795.00,TC,795,60,,636,percent of total billed charges,60% of total billed charges,636,48,,508.8,percent of total billed charges,48% of total billed charges,381.19,100,,,fee schedule,100% of bcbs custom fee schedule,381.19,100,,,fee schedule,100% of bcbs custom fee schedule,423.12,111,,,fee schedule,111% of bcbs custom fee schedule,450,100,,,case rate,pays based on per visit rate,927.5,70,,742,percent of total billed charges,70% of total billed charges,642.36,48.48,,513.888,percent of total billed charges,48.48% of total billed charges,140.55,116.15,,,fee schedule,116.51% of cms physician fee schedule,642.36,48.48,,513.888,percent of total billed charges,48.48% of total billed charges,927.5,70,,742,percent of total billed charges,70% of total billed charges,927.5,70,,742,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,642.36,48.48,,513.888,percent of total billed charges,48.48% of total billed charges,1192.5,90,,954,percent of total billed charges,90% of total billed charges,48.48,1192.5,
CT THORACIC SPINE W CNTRS,42003370,CDM,350,RC,72129,HCPCS,outpatient,,,1462.5,877.50,TC,877.5,60,,702,percent of total billed charges,60% of total billed charges,702,48,,561.6,percent of total billed charges,48% of total billed charges,517.63,100,,,fee schedule,100% of bcbs custom fee schedule,517.63,100,,,fee schedule,100% of bcbs custom fee schedule,574.57,111,,,fee schedule,111% of bcbs custom fee schedule,450,100,,,case rate,pays based on per visit rate,1023.75,70,,819,percent of total billed charges,70% of total billed charges,709.02,48.48,,567.216,percent of total billed charges,48.48% of total billed charges,183.91,116.15,,,fee schedule,116.51% of cms physician fee schedule,709.02,48.48,,567.216,percent of total billed charges,48.48% of total billed charges,1023.75,70,,819,percent of total billed charges,70% of total billed charges,1023.75,70,,819,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,709.02,48.48,,567.216,percent of total billed charges,48.48% of total billed charges,1316.25,90,,1053,percent of total billed charges,90% of total billed charges,48.48,1316.25,
CT THORACIC SPINE W/WO CNTRS,42003360,CDM,350,RC,72130,HCPCS,outpatient,,,2100,1260.00,TC,1260,60,,1008,percent of total billed charges,60% of total billed charges,1008,48,,806.4,percent of total billed charges,48% of total billed charges,615.7,100,,,fee schedule,100% of bcbs custom fee schedule,615.7,100,,,fee schedule,100% of bcbs custom fee schedule,683.43,111,,,fee schedule,111% of bcbs custom fee schedule,450,100,,,case rate,pays based on per visit rate,1470,70,,1176,percent of total billed charges,70% of total billed charges,1018.08,48.48,,814.464,percent of total billed charges,48.48% of total billed charges,214.3,116.15,,,fee schedule,116.51% of cms physician fee schedule,1018.08,48.48,,814.464,percent of total billed charges,48.48% of total billed charges,1470,70,,1176,percent of total billed charges,70% of total billed charges,1470,70,,1176,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,1018.08,48.48,,814.464,percent of total billed charges,48.48% of total billed charges,1890,90,,1512,percent of total billed charges,90% of total billed charges,48.48,1890,
CT LUMBAR SPINE W/O CNTRS,42003220,CDM,350,RC,72131,HCPCS,outpatient,,,1325,795.00,TC,795,60,,636,percent of total billed charges,60% of total billed charges,636,48,,508.8,percent of total billed charges,48% of total billed charges,381.19,100,,,fee schedule,100% of bcbs custom fee schedule,381.19,100,,,fee schedule,100% of bcbs custom fee schedule,423.12,111,,,fee schedule,111% of bcbs custom fee schedule,450,100,,,case rate,pays based on per visit rate,927.5,70,,742,percent of total billed charges,70% of total billed charges,642.36,48.48,,513.888,percent of total billed charges,48.48% of total billed charges,139.87,116.15,,,fee schedule,116.51% of cms physician fee schedule,642.36,48.48,,513.888,percent of total billed charges,48.48% of total billed charges,927.5,70,,742,percent of total billed charges,70% of total billed charges,927.5,70,,742,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,642.36,48.48,,513.888,percent of total billed charges,48.48% of total billed charges,1192.5,90,,954,percent of total billed charges,90% of total billed charges,48.48,1192.5,
CT LUMBAR SPINE W CNTRST,42003210,CDM,350,RC,72132,HCPCS,outpatient,,,1462.5,877.50,TC,877.5,60,,702,percent of total billed charges,60% of total billed charges,702,48,,561.6,percent of total billed charges,48% of total billed charges,517.63,100,,,fee schedule,100% of bcbs custom fee schedule,517.63,100,,,fee schedule,100% of bcbs custom fee schedule,574.57,111,,,fee schedule,111% of bcbs custom fee schedule,450,100,,,case rate,pays based on per visit rate,1023.75,70,,819,percent of total billed charges,70% of total billed charges,709.02,48.48,,567.216,percent of total billed charges,48.48% of total billed charges,182.8,116.15,,,fee schedule,116.51% of cms physician fee schedule,709.02,48.48,,567.216,percent of total billed charges,48.48% of total billed charges,1023.75,70,,819,percent of total billed charges,70% of total billed charges,1023.75,70,,819,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,709.02,48.48,,567.216,percent of total billed charges,48.48% of total billed charges,1316.25,90,,1053,percent of total billed charges,90% of total billed charges,48.48,1316.25,
CT LUMBAR SPINE W/WO CNTRS,42003200,CDM,350,RC,72133,HCPCS,outpatient,,,2092,1255.20,TC,1255.2,60,,1004.16,percent of total billed charges,60% of total billed charges,1004.16,48,,803.328,percent of total billed charges,48% of total billed charges,615.7,100,,,fee schedule,100% of bcbs custom fee schedule,615.7,100,,,fee schedule,100% of bcbs custom fee schedule,683.43,111,,,fee schedule,111% of bcbs custom fee schedule,450,100,,,case rate,pays based on per visit rate,1464.4,70,,1171.52,percent of total billed charges,70% of total billed charges,1014.2,48.48,,811.36,percent of total billed charges,48.48% of total billed charges,213.27,116.15,,,fee schedule,116.51% of cms physician fee schedule,1014.2,48.48,,811.36,percent of total billed charges,48.48% of total billed charges,1464.4,70,,1171.52,percent of total billed charges,70% of total billed charges,1464.4,70,,1171.52,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,1014.2,48.48,,811.36,percent of total billed charges,48.48% of total billed charges,1882.8,90,,1506.24,percent of total billed charges,90% of total billed charges,48.48,1882.8,
CT PELVIS W/O CONTRAST,42003290,CDM,350,RC,72192,HCPCS,outpatient,,,1325,795.00,TC,795,60,,636,percent of total billed charges,60% of total billed charges,636,48,,508.8,percent of total billed charges,48% of total billed charges,381.19,100,,,fee schedule,100% of bcbs custom fee schedule,381.19,100,,,fee schedule,100% of bcbs custom fee schedule,423.12,111,,,fee schedule,111% of bcbs custom fee schedule,450,100,,,case rate,pays based on per visit rate,927.5,70,,742,percent of total billed charges,70% of total billed charges,642.36,48.48,,513.888,percent of total billed charges,48.48% of total billed charges,144.47,116.15,,,fee schedule,116.51% of cms physician fee schedule,642.36,48.48,,513.888,percent of total billed charges,48.48% of total billed charges,927.5,70,,742,percent of total billed charges,70% of total billed charges,927.5,70,,742,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,642.36,48.48,,513.888,percent of total billed charges,48.48% of total billed charges,1192.5,90,,954,percent of total billed charges,90% of total billed charges,48.48,1192.5,
CT ABDOMEN/PELVIS WO CONT,42030100,CDM,350,RC,74176,HCPCS,outpatient,,,1325,795.00,TC,795,60,,636,percent of total billed charges,60% of total billed charges,636,48,,508.8,percent of total billed charges,48% of total billed charges,484.15,100,,,fee schedule,100% of bcbs custom fee schedule,484.15,100,,,fee schedule,100% of bcbs custom fee schedule,537.41,111,,,fee schedule,111% of bcbs custom fee schedule,450,100,,,case rate,pays based on per visit rate,927.5,70,,742,percent of total billed charges,70% of total billed charges,642.36,48.48,,513.888,percent of total billed charges,48.48% of total billed charges,200.16,116.15,,,fee schedule,116.51% of cms physician fee schedule,642.36,48.48,,513.888,percent of total billed charges,48.48% of total billed charges,927.5,70,,742,percent of total billed charges,70% of total billed charges,927.5,70,,742,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,642.36,48.48,,513.888,percent of total billed charges,48.48% of total billed charges,1192.5,90,,954,percent of total billed charges,90% of total billed charges,48.48,1192.5,
CT PELVIS W & WO CONTRAS,42003300,CDM,350,RC,72194,HCPCS,outpatient,,,2200,1320.00,TC,1320,60,,1056,percent of total billed charges,60% of total billed charges,1056,48,,844.8,percent of total billed charges,48% of total billed charges,615.7,100,,,fee schedule,100% of bcbs custom fee schedule,615.7,100,,,fee schedule,100% of bcbs custom fee schedule,683.43,111,,,fee schedule,111% of bcbs custom fee schedule,450,100,,,case rate,pays based on per visit rate,1540,70,,1232,percent of total billed charges,70% of total billed charges,1066.56,48.48,,853.248,percent of total billed charges,48.48% of total billed charges,270.18,116.15,,,fee schedule,116.51% of cms physician fee schedule,1066.56,48.48,,853.248,percent of total billed charges,48.48% of total billed charges,1540,70,,1232,percent of total billed charges,70% of total billed charges,1540,70,,1232,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,1066.56,48.48,,853.248,percent of total billed charges,48.48% of total billed charges,1980,90,,1584,percent of total billed charges,90% of total billed charges,48.48,1980,
CT UPPER EXT W/O CONTRAST,42004312,CDM,350,RC,73200,HCPCS,outpatient,,,1345,807.00,TC,807,60,,645.6,percent of total billed charges,60% of total billed charges,645.6,48,,516.48,percent of total billed charges,48% of total billed charges,371.34,100,,,fee schedule,100% of bcbs custom fee schedule,371.34,100,,,fee schedule,100% of bcbs custom fee schedule,412.19,111,,,fee schedule,111% of bcbs custom fee schedule,450,100,,,case rate,pays based on per visit rate,941.5,70,,753.2,percent of total billed charges,70% of total billed charges,652.06,48.48,,521.648,percent of total billed charges,48.48% of total billed charges,173.4,116.15,,,fee schedule,116.51% of cms physician fee schedule,652.06,48.48,,521.648,percent of total billed charges,48.48% of total billed charges,941.5,70,,753.2,percent of total billed charges,70% of total billed charges,941.5,70,,753.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,652.06,48.48,,521.648,percent of total billed charges,48.48% of total billed charges,1210.5,90,,968.4,percent of total billed charges,90% of total billed charges,48.48,1210.5,
CT UPPER EXT W CONTRAST,42003401,CDM,350,RC,73201,HCPCS,outpatient,,,1482.5,889.50,TC,889.5,60,,711.6,percent of total billed charges,60% of total billed charges,711.6,48,,569.28,percent of total billed charges,48% of total billed charges,443.53,100,,,fee schedule,100% of bcbs custom fee schedule,443.53,100,,,fee schedule,100% of bcbs custom fee schedule,492.32,111,,,fee schedule,111% of bcbs custom fee schedule,450,100,,,case rate,pays based on per visit rate,1037.75,70,,830.2,percent of total billed charges,70% of total billed charges,718.72,48.48,,574.976,percent of total billed charges,48.48% of total billed charges,215.69,116.15,,,fee schedule,116.51% of cms physician fee schedule,718.72,48.48,,574.976,percent of total billed charges,48.48% of total billed charges,1037.75,70,,830.2,percent of total billed charges,70% of total billed charges,1037.75,70,,830.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,718.72,48.48,,574.976,percent of total billed charges,48.48% of total billed charges,1334.25,90,,1067.4,percent of total billed charges,90% of total billed charges,48.48,1334.25,
CT UPPER EXT W/WO CONT,42003391,CDM,350,RC,73202,HCPCS,outpatient,,,2083,1249.80,TC,1249.8,60,,999.84,percent of total billed charges,60% of total billed charges,999.84,48,,799.872,percent of total billed charges,48% of total billed charges,556.93,100,,,fee schedule,100% of bcbs custom fee schedule,556.93,100,,,fee schedule,100% of bcbs custom fee schedule,618.19,111,,,fee schedule,111% of bcbs custom fee schedule,450,100,,,case rate,pays based on per visit rate,1458.1,70,,1166.48,percent of total billed charges,70% of total billed charges,1009.84,48.48,,807.872,percent of total billed charges,48.48% of total billed charges,266.11,116.15,,,fee schedule,116.51% of cms physician fee schedule,1009.84,48.48,,807.872,percent of total billed charges,48.48% of total billed charges,1458.1,70,,1166.48,percent of total billed charges,70% of total billed charges,1458.1,70,,1166.48,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,1009.84,48.48,,807.872,percent of total billed charges,48.48% of total billed charges,1874.7,90,,1499.76,percent of total billed charges,90% of total billed charges,48.48,1874.7,
CT LOWER EXT W/O CONTRAST,42003191,CDM,350,RC,73700,HCPCS,outpatient,,,1137.5,682.50,TC,682.5,60,,546,percent of total billed charges,60% of total billed charges,546,48,,436.8,percent of total billed charges,48% of total billed charges,371.34,100,,,fee schedule,100% of bcbs custom fee schedule,371.34,100,,,fee schedule,100% of bcbs custom fee schedule,412.19,111,,,fee schedule,111% of bcbs custom fee schedule,450,100,,,case rate,pays based on per visit rate,796.25,70,,637,percent of total billed charges,70% of total billed charges,551.46,48.48,,441.168,percent of total billed charges,48.48% of total billed charges,140.2,116.15,,,fee schedule,116.51% of cms physician fee schedule,551.46,48.48,,441.168,percent of total billed charges,48.48% of total billed charges,796.25,70,,637,percent of total billed charges,70% of total billed charges,796.25,70,,637,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,551.46,48.48,,441.168,percent of total billed charges,48.48% of total billed charges,1023.75,90,,819,percent of total billed charges,90% of total billed charges,48.48,1023.75,
CT LOWER EXT W CONTRAST,42003181,CDM,350,RC,73701,HCPCS,outpatient,,,1275,765.00,TC,765,60,,612,percent of total billed charges,60% of total billed charges,612,48,,489.6,percent of total billed charges,48% of total billed charges,443.53,100,,,fee schedule,100% of bcbs custom fee schedule,443.53,100,,,fee schedule,100% of bcbs custom fee schedule,492.32,111,,,fee schedule,111% of bcbs custom fee schedule,450,100,,,case rate,pays based on per visit rate,892.5,70,,714,percent of total billed charges,70% of total billed charges,618.12,48.48,,494.496,percent of total billed charges,48.48% of total billed charges,180.14,116.15,,,fee schedule,116.51% of cms physician fee schedule,618.12,48.48,,494.496,percent of total billed charges,48.48% of total billed charges,892.5,70,,714,percent of total billed charges,70% of total billed charges,892.5,70,,714,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,618.12,48.48,,494.496,percent of total billed charges,48.48% of total billed charges,1147.5,90,,918,percent of total billed charges,90% of total billed charges,48.48,1147.5,
CT LOWER EXT W/WO CONT,42003171,CDM,350,RC,73702,HCPCS,outpatient,,,2087,1252.20,TC,1252.2,60,,1001.76,percent of total billed charges,60% of total billed charges,1001.76,48,,801.408,percent of total billed charges,48% of total billed charges,556.93,100,,,fee schedule,100% of bcbs custom fee schedule,556.93,100,,,fee schedule,100% of bcbs custom fee schedule,618.19,111,,,fee schedule,111% of bcbs custom fee schedule,450,100,,,case rate,pays based on per visit rate,1460.9,70,,1168.72,percent of total billed charges,70% of total billed charges,1011.78,48.48,,809.424,percent of total billed charges,48.48% of total billed charges,210.23,116.15,,,fee schedule,116.51% of cms physician fee schedule,1011.78,48.48,,809.424,percent of total billed charges,48.48% of total billed charges,1460.9,70,,1168.72,percent of total billed charges,70% of total billed charges,1460.9,70,,1168.72,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,1011.78,48.48,,809.424,percent of total billed charges,48.48% of total billed charges,1878.3,90,,1502.64,percent of total billed charges,90% of total billed charges,48.48,1878.3,
CT ABDOMEN W/O CONTRAST,42003040,CDM,350,RC,74150,HCPCS,outpatient,,,1462,877.20,TC,877.2,60,,701.76,percent of total billed charges,60% of total billed charges,701.76,48,,561.408,percent of total billed charges,48% of total billed charges,381.19,100,,,fee schedule,100% of bcbs custom fee schedule,381.19,100,,,fee schedule,100% of bcbs custom fee schedule,423.12,111,,,fee schedule,111% of bcbs custom fee schedule,450,100,,,case rate,pays based on per visit rate,1023.4,70,,818.72,percent of total billed charges,70% of total billed charges,708.78,48.48,,567.024,percent of total billed charges,48.48% of total billed charges,148.67,116.15,,,fee schedule,116.51% of cms physician fee schedule,708.78,48.48,,567.024,percent of total billed charges,48.48% of total billed charges,1023.4,70,,818.72,percent of total billed charges,70% of total billed charges,1023.4,70,,818.72,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,708.78,48.48,,567.024,percent of total billed charges,48.48% of total billed charges,1315.8,90,,1052.64,percent of total billed charges,90% of total billed charges,48.48,1315.8,
CT ABDOMEN W CONTRAST,42003030,CDM,350,RC,74160,HCPCS,outpatient,,,1743,1045.80,TC,1045.8,60,,836.64,percent of total billed charges,60% of total billed charges,836.64,48,,669.312,percent of total billed charges,48% of total billed charges,513.42,100,,,fee schedule,100% of bcbs custom fee schedule,513.42,100,,,fee schedule,100% of bcbs custom fee schedule,569.9,111,,,fee schedule,111% of bcbs custom fee schedule,450,100,,,case rate,pays based on per visit rate,1220.1,70,,976.08,percent of total billed charges,70% of total billed charges,845.01,48.48,,676.008,percent of total billed charges,48.48% of total billed charges,250.2,116.15,,,fee schedule,116.51% of cms physician fee schedule,845.01,48.48,,676.008,percent of total billed charges,48.48% of total billed charges,1220.1,70,,976.08,percent of total billed charges,70% of total billed charges,1220.1,70,,976.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,845.01,48.48,,676.008,percent of total billed charges,48.48% of total billed charges,1568.7,90,,1254.96,percent of total billed charges,90% of total billed charges,48.48,1568.7,
CT ABDOMEN W/WO CONTRAST,42003020,CDM,350,RC,74170,HCPCS,outpatient,,,2685,1611.00,TC,1611,60,,1288.8,percent of total billed charges,60% of total billed charges,1288.8,48,,1031.04,percent of total billed charges,48% of total billed charges,615.7,100,,,fee schedule,100% of bcbs custom fee schedule,615.7,100,,,fee schedule,100% of bcbs custom fee schedule,683.43,111,,,fee schedule,111% of bcbs custom fee schedule,450,100,,,case rate,pays based on per visit rate,1879.5,70,,1503.6,percent of total billed charges,70% of total billed charges,1301.69,48.48,,1041.352,percent of total billed charges,48.48% of total billed charges,280.97,116.15,,,fee schedule,116.51% of cms physician fee schedule,1301.69,48.48,,1041.352,percent of total billed charges,48.48% of total billed charges,1879.5,70,,1503.6,percent of total billed charges,70% of total billed charges,1879.5,70,,1503.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,1301.69,48.48,,1041.352,percent of total billed charges,48.48% of total billed charges,2416.5,90,,1933.2,percent of total billed charges,90% of total billed charges,48.48,2416.5,
CT ABDOMEN/PELVIS W/WO,42030200,CDM,350,RC,74178,HCPCS,outpatient,,,2328,1396.80,TC,1396.8,60,,1117.44,percent of total billed charges,60% of total billed charges,1117.44,48,,893.952,percent of total billed charges,48% of total billed charges,857.07,100,,,fee schedule,100% of bcbs custom fee schedule,857.07,100,,,fee schedule,100% of bcbs custom fee schedule,951.35,111,,,fee schedule,111% of bcbs custom fee schedule,450,100,,,case rate,pays based on per visit rate,1629.6,70,,1303.68,percent of total billed charges,70% of total billed charges,1128.61,48.48,,902.888,percent of total billed charges,48.48% of total billed charges,365.93,116.15,,,fee schedule,116.51% of cms physician fee schedule,1128.61,48.48,,902.888,percent of total billed charges,48.48% of total billed charges,1629.6,70,,1303.68,percent of total billed charges,70% of total billed charges,1629.6,70,,1303.68,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,1128.61,48.48,,902.888,percent of total billed charges,48.48% of total billed charges,2095.2,90,,1676.16,percent of total billed charges,90% of total billed charges,48.48,2095.2,
CT ABDOMEN/PELVIS WITH CONTRAST,42030300,CDM,350,RC,74177,HCPCS,outpatient,,,1500,900.00,TC,900,60,,720,percent of total billed charges,60% of total billed charges,720,48,,576,percent of total billed charges,48% of total billed charges,658.17,100,,,fee schedule,100% of bcbs custom fee schedule,658.17,100,,,fee schedule,100% of bcbs custom fee schedule,730.57,111,,,fee schedule,111% of bcbs custom fee schedule,450,100,,,case rate,pays based on per visit rate,1050,70,,840,percent of total billed charges,70% of total billed charges,727.2,48.48,,581.76,percent of total billed charges,48.48% of total billed charges,326.2,116.15,,,fee schedule,116.51% of cms physician fee schedule,727.2,48.48,,581.76,percent of total billed charges,48.48% of total billed charges,1050,70,,840,percent of total billed charges,70% of total billed charges,1050,70,,840,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,727.2,48.48,,581.76,percent of total billed charges,48.48% of total billed charges,1350,90,,1080,percent of total billed charges,90% of total billed charges,48.48,1350,
CT PELVIS WITH CONTRAST,42003310,CDM,350,RC,72193,HCPCS,outpatient,,,1543,925.80,TC,925.8,60,,740.64,percent of total billed charges,60% of total billed charges,740.64,48,,592.512,percent of total billed charges,48% of total billed charges,513.42,100,,,fee schedule,100% of bcbs custom fee schedule,513.42,100,,,fee schedule,100% of bcbs custom fee schedule,569.9,111,,,fee schedule,111% of bcbs custom fee schedule,450,100,,,case rate,pays based on per visit rate,1080.1,70,,864.08,percent of total billed charges,70% of total billed charges,748.05,48.48,,598.44,percent of total billed charges,48.48% of total billed charges,245.16,116.15,,,fee schedule,116.51% of cms physician fee schedule,748.05,48.48,,598.44,percent of total billed charges,48.48% of total billed charges,1080.1,70,,864.08,percent of total billed charges,70% of total billed charges,1080.1,70,,864.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,748.05,48.48,,598.44,percent of total billed charges,48.48% of total billed charges,1388.7,90,,1110.96,percent of total billed charges,90% of total billed charges,48.48,1388.7,
CT ANGIOGRAPHY CHEST,42003002,CDM,350,RC,71275,HCPCS,outpatient,,,3100,1860.00,TC,1860,60,,1488,percent of total billed charges,60% of total billed charges,1488,48,,1190.4,percent of total billed charges,48% of total billed charges,602.32,100,,,fee schedule,100% of bcbs custom fee schedule,602.32,100,,,fee schedule,100% of bcbs custom fee schedule,668.58,111,,,fee schedule,111% of bcbs custom fee schedule,450,100,,,case rate,pays based on per visit rate,2170,70,,1736,percent of total billed charges,70% of total billed charges,1502.88,48.48,,1202.304,percent of total billed charges,48.48% of total billed charges,303.37,116.15,,,fee schedule,116.51% of cms physician fee schedule,1502.88,48.48,,1202.304,percent of total billed charges,48.48% of total billed charges,2170,70,,1736,percent of total billed charges,70% of total billed charges,2170,70,,1736,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,1502.88,48.48,,1202.304,percent of total billed charges,48.48% of total billed charges,2790,90,,2232,percent of total billed charges,90% of total billed charges,48.48,2790,
IV CONTRAST,35030172,CDM,255,RC,Q9967,HCPCS,outpatient,,,150,90.00,,90,60,,72,percent of total billed charges,60% of total billed charges,72,48,,57.6,percent of total billed charges,48% of total billed charges,0.11,100,,,fee schedule,100% of bcbs custom fee schedule,0.11,100,,,fee schedule,100% of bcbs custom fee schedule,0.12,111,,,fee schedule,111% of bcbs custom fee schedule,75,50,,60,percent of total billed charges,50% of total billed charges,105,70,,84,percent of total billed charges,70% of total billed charges,72.72,48.48,,58.176,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,72.72,48.48,,58.176,percent of total billed charges,48.48% of total billed charges,105,70,,84,percent of total billed charges,70% of total billed charges,105,70,,84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,72.72,48.48,,58.176,percent of total billed charges,48.48% of total billed charges,135,90,,108,percent of total billed charges,90% of total billed charges,48.48,135,
VITAL CAPACITY TEST,43102045,CDM,460,RC,94150,HCPCS,outpatient,,,250,150.00,,150,60,,120,percent of total billed charges,60% of total billed charges,120,48,,96,percent of total billed charges,48% of total billed charges,85.61,100,,,fee schedule,100% of bcbs custom fee schedule,85.61,100,,,fee schedule,100% of bcbs custom fee schedule,95.03,111,,,fee schedule,111% of bcbs custom fee schedule,125,50,,100,percent of total billed charges,50% of total billed charges,175,70,,140,percent of total billed charges,70% of total billed charges,121.2,48.48,,96.96,percent of total billed charges,48.48% of total billed charges,26.27,116.15,,,fee schedule,116.51% of cms physician fee schedule,121.2,48.48,,96.96,percent of total billed charges,48.48% of total billed charges,175,70,,140,percent of total billed charges,70% of total billed charges,175,70,,140,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,121.2,48.48,,96.96,percent of total billed charges,48.48% of total billed charges,225,90,,180,percent of total billed charges,90% of total billed charges,48.48,225,
LUNG FUNCTION TEST (MBC/MVV),43102050,CDM,460,RC,94200,HCPCS,outpatient,,,100,60.00,,60,60,,48,percent of total billed charges,60% of total billed charges,48,48,,38.4,percent of total billed charges,48% of total billed charges,85.61,100,,,fee schedule,100% of bcbs custom fee schedule,85.61,100,,,fee schedule,100% of bcbs custom fee schedule,95.03,111,,,fee schedule,111% of bcbs custom fee schedule,50,50,,40,percent of total billed charges,50% of total billed charges,70,70,,56,percent of total billed charges,70% of total billed charges,48.48,48.48,,38.784,percent of total billed charges,48.48% of total billed charges,15.68,116.15,,,fee schedule,116.51% of cms physician fee schedule,48.48,48.48,,38.784,percent of total billed charges,48.48% of total billed charges,70,70,,56,percent of total billed charges,70% of total billed charges,70,70,,56,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,48.48,48.48,,38.784,percent of total billed charges,48.48% of total billed charges,90,90,,72,percent of total billed charges,90% of total billed charges,48.48,90,
RESPIRATORY FLOW VOLUME LOOP,,,460,RC,94375,HCPCS,outpatient,,,437.5,262.50,,262.5,60,,210,percent of total billed charges,60% of total billed charges,210,48,,168,percent of total billed charges,48% of total billed charges,85.61,100,,,fee schedule,100% of bcbs custom fee schedule,85.61,100,,,fee schedule,100% of bcbs custom fee schedule,95.03,111,,,fee schedule,111% of bcbs custom fee schedule,218.75,50,,175,percent of total billed charges,50% of total billed charges,306.25,70,,245,percent of total billed charges,70% of total billed charges,212.1,48.48,,169.68,percent of total billed charges,48.48% of total billed charges,41.31,116.15,,,fee schedule,116.51% of cms physician fee schedule,212.1,48.48,,169.68,percent of total billed charges,48.48% of total billed charges,306.25,70,,245,percent of total billed charges,70% of total billed charges,306.25,70,,245,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,212.1,48.48,,169.68,percent of total billed charges,48.48% of total billed charges,393.75,90,,315,percent of total billed charges,90% of total billed charges,48.48,393.75,
PULMONARY STRESS TESTING,43102016,CDM,460,RC,94618,HCPCS,outpatient,,,250,150.00,,150,60,,120,percent of total billed charges,60% of total billed charges,120,48,,96,percent of total billed charges,48% of total billed charges,125.28,100,,,fee schedule,100% of bcbs custom fee schedule,125.28,100,,,fee schedule,100% of bcbs custom fee schedule,139.06,111,,,fee schedule,111% of bcbs custom fee schedule,125,50,,100,percent of total billed charges,50% of total billed charges,175,70,,140,percent of total billed charges,70% of total billed charges,121.2,48.48,,96.96,percent of total billed charges,48.48% of total billed charges,37.16,116.15,,,fee schedule,116.51% of cms physician fee schedule,121.2,48.48,,96.96,percent of total billed charges,48.48% of total billed charges,175,70,,140,percent of total billed charges,70% of total billed charges,175,70,,140,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,121.2,48.48,,96.96,percent of total billed charges,48.48% of total billed charges,225,90,,180,percent of total billed charges,90% of total billed charges,48.48,225,
CPET - COMPLEX,,,460,RC,94621,HCPCS,outpatient,,,500,300.00,,300,60,,240,percent of total billed charges,60% of total billed charges,240,48,,192,percent of total billed charges,48% of total billed charges,354.13,100,,,fee schedule,100% of bcbs custom fee schedule,354.13,100,,,fee schedule,100% of bcbs custom fee schedule,393.08,111,,,fee schedule,111% of bcbs custom fee schedule,250,50,,200,percent of total billed charges,50% of total billed charges,350,70,,280,percent of total billed charges,70% of total billed charges,242.4,48.48,,193.92,percent of total billed charges,48.48% of total billed charges,165.1,116.15,,,fee schedule,116.51% of cms physician fee schedule,242.4,48.48,,193.92,percent of total billed charges,48.48% of total billed charges,350,70,,280,percent of total billed charges,70% of total billed charges,350,70,,280,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,242.4,48.48,,193.92,percent of total billed charges,48.48% of total billed charges,450,90,,360,percent of total billed charges,90% of total billed charges,48.48,450,
PULMONARY REHAB W/O O2 MNTR,,,460,RC,94625,HCPCS,outpatient,,,100,60.00,,60,60,,48,percent of total billed charges,60% of total billed charges,48,48,,38.4,percent of total billed charges,48% of total billed charges,50,50,,40,percent of total billed charges,50% of total billed charges,50,50,,40,percent of total billed charges,50% of total billed charges,50,50,,40,percent of total billed charges,50% of total billed charges,50,50,,40,percent of total billed charges,50% of total billed charges,70,70,,56,percent of total billed charges,70% of total billed charges,48.48,48.48,,38.784,percent of total billed charges,48.48% of total billed charges,20.77,116.15,,,fee schedule,116.51% of cms physician fee schedule,48.48,48.48,,38.784,percent of total billed charges,48.48% of total billed charges,70,70,,56,percent of total billed charges,70% of total billed charges,70,70,,56,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,48.48,48.48,,38.784,percent of total billed charges,48.48% of total billed charges,90,90,,72,percent of total billed charges,90% of total billed charges,48.48,90,
PULMONARY REHAB W/ O2 MNTR,,,460,RC,94626,HCPCS,outpatient,,,100,60.00,,60,60,,48,percent of total billed charges,60% of total billed charges,48,48,,38.4,percent of total billed charges,48% of total billed charges,50,50,,40,percent of total billed charges,50% of total billed charges,50,50,,40,percent of total billed charges,50% of total billed charges,50,50,,40,percent of total billed charges,50% of total billed charges,50,50,,40,percent of total billed charges,50% of total billed charges,70,70,,56,percent of total billed charges,70% of total billed charges,48.48,48.48,,38.784,percent of total billed charges,48.48% of total billed charges,30.63,116.15,,,fee schedule,116.51% of cms physician fee schedule,48.48,48.48,,38.784,percent of total billed charges,48.48% of total billed charges,70,70,,56,percent of total billed charges,70% of total billed charges,70,70,,56,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,48.48,48.48,,38.784,percent of total billed charges,48.48% of total billed charges,90,90,,72,percent of total billed charges,90% of total billed charges,48.48,90,
AIRWAY INHALATION TREATMENT,43102004,CDM,460,RC,94640,HCPCS,outpatient,,,250,150.00,,150,60,,120,percent of total billed charges,60% of total billed charges,120,48,,96,percent of total billed charges,48% of total billed charges,44.88,100,,,fee schedule,100% of bcbs custom fee schedule,44.88,100,,,fee schedule,100% of bcbs custom fee schedule,49.82,111,,,fee schedule,111% of bcbs custom fee schedule,125,50,,100,percent of total billed charges,50% of total billed charges,175,70,,140,percent of total billed charges,70% of total billed charges,121.2,48.48,,96.96,percent of total billed charges,48.48% of total billed charges,8.22,116.15,,,fee schedule,116.51% of cms physician fee schedule,121.2,48.48,,96.96,percent of total billed charges,48.48% of total billed charges,175,70,,140,percent of total billed charges,70% of total billed charges,175,70,,140,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,121.2,48.48,,96.96,percent of total billed charges,48.48% of total billed charges,225,90,,180,percent of total billed charges,90% of total billed charges,48.48,225,
CPAP - PULMONARY,43102055,CDM,460,RC,94660,HCPCS,outpatient,,,437.5,262.50,,262.5,60,,210,percent of total billed charges,60% of total billed charges,210,48,,168,percent of total billed charges,48% of total billed charges,162.81,100,,,fee schedule,100% of bcbs custom fee schedule,162.81,100,,,fee schedule,100% of bcbs custom fee schedule,180.72,111,,,fee schedule,111% of bcbs custom fee schedule,218.75,50,,175,percent of total billed charges,50% of total billed charges,306.25,70,,245,percent of total billed charges,70% of total billed charges,212.1,48.48,,169.68,percent of total billed charges,48.48% of total billed charges,41.51,116.15,,,fee schedule,116.51% of cms physician fee schedule,212.1,48.48,,169.68,percent of total billed charges,48.48% of total billed charges,306.25,70,,245,percent of total billed charges,70% of total billed charges,306.25,70,,245,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,212.1,48.48,,169.68,percent of total billed charges,48.48% of total billed charges,393.75,90,,315,percent of total billed charges,90% of total billed charges,48.48,393.75,
NEG PRESS VENTILATION CNP,,,460,RC,94662,HCPCS,outpatient,,,750,450.00,,450,60,,360,percent of total billed charges,60% of total billed charges,360,48,,288,percent of total billed charges,48% of total billed charges,293.41,100,,,fee schedule,100% of bcbs custom fee schedule,293.41,100,,,fee schedule,100% of bcbs custom fee schedule,325.69,111,,,fee schedule,111% of bcbs custom fee schedule,375,50,,300,percent of total billed charges,50% of total billed charges,525,70,,420,percent of total billed charges,70% of total billed charges,363.6,48.48,,290.88,percent of total billed charges,48.48% of total billed charges,39.14,116.15,,,fee schedule,116.51% of cms physician fee schedule,363.6,48.48,,290.88,percent of total billed charges,48.48% of total billed charges,525,70,,420,percent of total billed charges,70% of total billed charges,525,70,,420,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,363.6,48.48,,290.88,percent of total billed charges,48.48% of total billed charges,675,90,,540,percent of total billed charges,90% of total billed charges,48.48,675,
DEMO/EVAL USE OF INHALER,43102005,CDM,460,RC,94664,HCPCS,outpatient,,,312.5,187.50,,187.5,60,,150,percent of total billed charges,60% of total billed charges,150,48,,120,percent of total billed charges,48% of total billed charges,44.88,100,,,fee schedule,100% of bcbs custom fee schedule,44.88,100,,,fee schedule,100% of bcbs custom fee schedule,49.82,111,,,fee schedule,111% of bcbs custom fee schedule,156.25,50,,125,percent of total billed charges,50% of total billed charges,218.75,70,,175,percent of total billed charges,70% of total billed charges,151.5,48.48,,121.2,percent of total billed charges,48.48% of total billed charges,18.49,116.15,,,fee schedule,116.51% of cms physician fee schedule,151.5,48.48,,121.2,percent of total billed charges,48.48% of total billed charges,218.75,70,,175,percent of total billed charges,70% of total billed charges,218.75,70,,175,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,151.5,48.48,,121.2,percent of total billed charges,48.48% of total billed charges,281.25,90,,225,percent of total billed charges,90% of total billed charges,48.48,281.25,
CHEST WALL MANIPULATION INITIAL,43102022,CDM,460,RC,94667,HCPCS,outpatient,,,200,120.00,,120,60,,96,percent of total billed charges,60% of total billed charges,96,48,,76.8,percent of total billed charges,48% of total billed charges,44.88,100,,,fee schedule,100% of bcbs custom fee schedule,44.88,100,,,fee schedule,100% of bcbs custom fee schedule,49.82,111,,,fee schedule,111% of bcbs custom fee schedule,100,50,,80,percent of total billed charges,50% of total billed charges,140,70,,112,percent of total billed charges,70% of total billed charges,96.96,48.48,,77.568,percent of total billed charges,48.48% of total billed charges,25.6,116.15,,,fee schedule,116.51% of cms physician fee schedule,96.96,48.48,,77.568,percent of total billed charges,48.48% of total billed charges,140,70,,112,percent of total billed charges,70% of total billed charges,140,70,,112,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,96.96,48.48,,77.568,percent of total billed charges,48.48% of total billed charges,180,90,,144,percent of total billed charges,90% of total billed charges,48.48,180,
CHEST WALL MANIPULATION SUBSEQ,43102063,CDM,460,RC,94668,HCPCS,outpatient,,,200,120.00,,120,60,,96,percent of total billed charges,60% of total billed charges,96,48,,76.8,percent of total billed charges,48% of total billed charges,44.88,100,,,fee schedule,100% of bcbs custom fee schedule,44.88,100,,,fee schedule,100% of bcbs custom fee schedule,49.82,111,,,fee schedule,111% of bcbs custom fee schedule,100,50,,80,percent of total billed charges,50% of total billed charges,140,70,,112,percent of total billed charges,70% of total billed charges,96.96,48.48,,77.568,percent of total billed charges,48.48% of total billed charges,40.27,116.15,,,fee schedule,116.51% of cms physician fee schedule,96.96,48.48,,77.568,percent of total billed charges,48.48% of total billed charges,140,70,,112,percent of total billed charges,70% of total billed charges,140,70,,112,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,96.96,48.48,,77.568,percent of total billed charges,48.48% of total billed charges,180,90,,144,percent of total billed charges,90% of total billed charges,48.48,180,
MECHANICAL CHEST WALL OSCILLATION,,,460,RC,94669,HCPCS,outpatient,,,375,225.00,,225,60,,180,percent of total billed charges,60% of total billed charges,180,48,,144,percent of total billed charges,48% of total billed charges,86.57,100,,,fee schedule,100% of bcbs custom fee schedule,86.57,100,,,fee schedule,100% of bcbs custom fee schedule,96.09,111,,,fee schedule,111% of bcbs custom fee schedule,187.5,50,,150,percent of total billed charges,50% of total billed charges,262.5,70,,210,percent of total billed charges,70% of total billed charges,181.8,48.48,,145.44,percent of total billed charges,48.48% of total billed charges,21.2,116.15,,,fee schedule,116.51% of cms physician fee schedule,181.8,48.48,,145.44,percent of total billed charges,48.48% of total billed charges,262.5,70,,210,percent of total billed charges,70% of total billed charges,262.5,70,,210,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,181.8,48.48,,145.44,percent of total billed charges,48.48% of total billed charges,337.5,90,,270,percent of total billed charges,90% of total billed charges,48.48,337.5,
PFT BY GAS DILUTION/WASHOUT,,,460,RC,94727,HCPCS,outpatient,,,300,180.00,,180,60,,144,percent of total billed charges,60% of total billed charges,144,48,,115.2,percent of total billed charges,48% of total billed charges,114.31,100,,,fee schedule,100% of bcbs custom fee schedule,114.31,100,,,fee schedule,100% of bcbs custom fee schedule,126.88,111,,,fee schedule,111% of bcbs custom fee schedule,150,50,,120,percent of total billed charges,50% of total billed charges,210,70,,168,percent of total billed charges,70% of total billed charges,145.44,48.48,,116.352,percent of total billed charges,48.48% of total billed charges,46.83,116.15,,,fee schedule,116.51% of cms physician fee schedule,145.44,48.48,,116.352,percent of total billed charges,48.48% of total billed charges,210,70,,168,percent of total billed charges,70% of total billed charges,210,70,,168,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,145.44,48.48,,116.352,percent of total billed charges,48.48% of total billed charges,270,90,,216,percent of total billed charges,90% of total billed charges,48.48,270,
AIRWY RESIST BY OSCILLOMETRY,,,460,RC,94728,HCPCS,outpatient,,,375,225.00,,225,60,,180,percent of total billed charges,60% of total billed charges,180,48,,144,percent of total billed charges,48% of total billed charges,114.31,100,,,fee schedule,100% of bcbs custom fee schedule,114.31,100,,,fee schedule,100% of bcbs custom fee schedule,126.88,111,,,fee schedule,111% of bcbs custom fee schedule,187.5,50,,150,percent of total billed charges,50% of total billed charges,262.5,70,,210,percent of total billed charges,70% of total billed charges,181.8,48.48,,145.44,percent of total billed charges,48.48% of total billed charges,46.49,116.15,,,fee schedule,116.51% of cms physician fee schedule,181.8,48.48,,145.44,percent of total billed charges,48.48% of total billed charges,262.5,70,,210,percent of total billed charges,70% of total billed charges,262.5,70,,210,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,181.8,48.48,,145.44,percent of total billed charges,48.48% of total billed charges,337.5,90,,270,percent of total billed charges,90% of total billed charges,48.48,337.5,
DIFFUSING CAPACITY TEST,43104033,CDM,460,RC,94729,HCPCS,outpatient,,,125,75.00,,75,60,,60,percent of total billed charges,60% of total billed charges,60,48,,48,percent of total billed charges,48% of total billed charges,137.2,100,,,fee schedule,100% of bcbs custom fee schedule,137.2,100,,,fee schedule,100% of bcbs custom fee schedule,152.29,111,,,fee schedule,111% of bcbs custom fee schedule,62.5,50,,50,percent of total billed charges,50% of total billed charges,87.5,70,,70,percent of total billed charges,70% of total billed charges,60.6,48.48,,48.48,percent of total billed charges,48.48% of total billed charges,58.69,116.15,,,fee schedule,116.51% of cms physician fee schedule,60.6,48.48,,48.48,percent of total billed charges,48.48% of total billed charges,87.5,70,,70,percent of total billed charges,70% of total billed charges,87.5,70,,70,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,60.6,48.48,,48.48,percent of total billed charges,48.48% of total billed charges,112.5,90,,90,percent of total billed charges,90% of total billed charges,48.48,112.5,
PULMONARY SERVICE/PROCEDURE,43102014,CDM,460,RC,94799,HCPCS,outpatient,,,250,150.00,,150,60,,120,percent of total billed charges,60% of total billed charges,120,48,,96,percent of total billed charges,48% of total billed charges,85.61,100,,,fee schedule,100% of bcbs custom fee schedule,85.61,100,,,fee schedule,100% of bcbs custom fee schedule,95.03,111,,,fee schedule,111% of bcbs custom fee schedule,125,50,,100,percent of total billed charges,50% of total billed charges,175,70,,140,percent of total billed charges,70% of total billed charges,121.2,48.48,,96.96,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,121.2,48.48,,96.96,percent of total billed charges,48.48% of total billed charges,175,70,,140,percent of total billed charges,70% of total billed charges,175,70,,140,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,121.2,48.48,,96.96,percent of total billed charges,48.48% of total billed charges,225,90,,180,percent of total billed charges,90% of total billed charges,48.48,225,
THERAPEUTIC PROCD STRG/ENDUR,,,450,RC,G0237,HCPCS,outpatient,,,187.5,112.50,,112.5,60,,90,percent of total billed charges,60% of total billed charges,90,48,,72,percent of total billed charges,48% of total billed charges,51.36,100,,,fee schedule,100% of bcbs custom fee schedule,51.36,100,,,fee schedule,100% of bcbs custom fee schedule,57.01,111,,,fee schedule,111% of bcbs custom fee schedule,93.75,50,,75,percent of total billed charges,50% of total billed charges,131.25,70,,105,percent of total billed charges,70% of total billed charges,90.9,48.48,,72.72,percent of total billed charges,48.48% of total billed charges,11.62,116.15,,,fee schedule,116.51% of cms physician fee schedule,90.9,48.48,,72.72,percent of total billed charges,48.48% of total billed charges,131.25,70,,105,percent of total billed charges,70% of total billed charges,131.25,70,,105,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,90.9,48.48,,72.72,percent of total billed charges,48.48% of total billed charges,168.75,90,,135,percent of total billed charges,90% of total billed charges,48.48,168.75,
THERAPEUTIC PROCD RESP FUNCTION - INDIV,,,460,RC,G0238,HCPCS,outpatient,,,187.5,112.50,,112.5,60,,90,percent of total billed charges,60% of total billed charges,90,48,,72,percent of total billed charges,48% of total billed charges,51.36,100,,,fee schedule,100% of bcbs custom fee schedule,51.36,100,,,fee schedule,100% of bcbs custom fee schedule,57.01,111,,,fee schedule,111% of bcbs custom fee schedule,93.75,50,,75,percent of total billed charges,50% of total billed charges,131.25,70,,105,percent of total billed charges,70% of total billed charges,90.9,48.48,,72.72,percent of total billed charges,48.48% of total billed charges,10.59,116.15,,,fee schedule,116.51% of cms physician fee schedule,90.9,48.48,,72.72,percent of total billed charges,48.48% of total billed charges,131.25,70,,105,percent of total billed charges,70% of total billed charges,131.25,70,,105,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,90.9,48.48,,72.72,percent of total billed charges,48.48% of total billed charges,168.75,90,,135,percent of total billed charges,90% of total billed charges,48.48,168.75,
THERAPEUTIC PROCD RESP FUNCTION - GROUP,,,460,RC,G0239,HCPCS,outpatient,,,250,150.00,,150,60,,120,percent of total billed charges,60% of total billed charges,120,48,,96,percent of total billed charges,48% of total billed charges,51.36,100,,,fee schedule,100% of bcbs custom fee schedule,51.36,100,,,fee schedule,100% of bcbs custom fee schedule,57.01,111,,,fee schedule,111% of bcbs custom fee schedule,125,50,,100,percent of total billed charges,50% of total billed charges,175,70,,140,percent of total billed charges,70% of total billed charges,121.2,48.48,,96.96,percent of total billed charges,48.48% of total billed charges,13.31,116.15,,,fee schedule,116.51% of cms physician fee schedule,121.2,48.48,,96.96,percent of total billed charges,48.48% of total billed charges,175,70,,140,percent of total billed charges,70% of total billed charges,175,70,,140,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,121.2,48.48,,96.96,percent of total billed charges,48.48% of total billed charges,225,90,,180,percent of total billed charges,90% of total billed charges,48.48,225,
SPIROMETRY - PULMONARY,43102036,CDM,460,RC,94010,HCPCS,outpatient,,,225,135.00,,32,100,,,fee schedule,100% of aetna fee schedule,108,48,,86.4,percent of total billed charges,48% of total billed charges,125.28,100,,,fee schedule,100% of bcbs custom fee schedule,125.28,100,,,fee schedule,100% of bcbs custom fee schedule,139.06,111,,,fee schedule,111% of bcbs custom fee schedule,112.5,50,,90,percent of total billed charges,50% of total billed charges,157.5,70,,126,percent of total billed charges,70% of total billed charges,109.08,48.48,,87.264,percent of total billed charges,48.48% of total billed charges,28.79,116.15,,,fee schedule,116.51% of cms physician fee schedule,109.08,48.48,,87.264,percent of total billed charges,48.48% of total billed charges,157.5,70,,126,percent of total billed charges,70% of total billed charges,157.5,70,,126,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,109.08,48.48,,87.264,percent of total billed charges,48.48% of total billed charges,202.5,90,,162,percent of total billed charges,90% of total billed charges,48.48,202.5,
BRONCHOSPASM EVALUATION,43102037,CDM,460,RC,94060,HCPCS,outpatient,,,437.5,262.50,,262.5,60,,210,percent of total billed charges,60% of total billed charges,210,48,,168,percent of total billed charges,48% of total billed charges,125.28,100,,,fee schedule,100% of bcbs custom fee schedule,125.28,100,,,fee schedule,100% of bcbs custom fee schedule,139.06,111,,,fee schedule,111% of bcbs custom fee schedule,218.75,50,,175,percent of total billed charges,50% of total billed charges,306.25,70,,245,percent of total billed charges,70% of total billed charges,212.1,48.48,,169.68,percent of total billed charges,48.48% of total billed charges,40.88,116.15,,,fee schedule,116.51% of cms physician fee schedule,212.1,48.48,,169.68,percent of total billed charges,48.48% of total billed charges,306.25,70,,245,percent of total billed charges,70% of total billed charges,306.25,70,,245,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,212.1,48.48,,169.68,percent of total billed charges,48.48% of total billed charges,393.75,90,,315,percent of total billed charges,90% of total billed charges,48.48,393.75,
US AORTA ABDO LIMITED,42002060,CDM,402,RC,76775,HCPCS,outpatient,,,344,206.40,TC,206.4,60,,165.12,percent of total billed charges,60% of total billed charges,165.12,48,,132.096,percent of total billed charges,48% of total billed charges,140.33,100,,,fee schedule,100% of bcbs custom fee schedule,140.33,100,,,fee schedule,100% of bcbs custom fee schedule,155.77,111,,,fee schedule,111% of bcbs custom fee schedule,172,50,,137.6,percent of total billed charges,50% of total billed charges,240.8,70,,192.64,percent of total billed charges,70% of total billed charges,166.77,48.48,,133.416,percent of total billed charges,48.48% of total billed charges,63.81,116.15,,,fee schedule,116.51% of cms physician fee schedule,166.77,48.48,,133.416,percent of total billed charges,48.48% of total billed charges,240.8,70,,192.64,percent of total billed charges,70% of total billed charges,240.8,70,,192.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,166.77,48.48,,133.416,percent of total billed charges,48.48% of total billed charges,309.6,90,,247.68,percent of total billed charges,90% of total billed charges,48.48,309.6,
US OB <14 WKS SINGLE,42002236,CDM,402,RC,76801,HCPCS,outpatient,,,735,441.00,TC,441,60,,352.8,percent of total billed charges,60% of total billed charges,352.8,48,,282.24,percent of total billed charges,48% of total billed charges,158.46,100,,,fee schedule,100% of bcbs custom fee schedule,158.46,100,,,fee schedule,100% of bcbs custom fee schedule,175.89,111,,,fee schedule,111% of bcbs custom fee schedule,367.5,50,,294,percent of total billed charges,50% of total billed charges,514.5,70,,411.6,percent of total billed charges,70% of total billed charges,356.33,48.48,,285.064,percent of total billed charges,48.48% of total billed charges,124.48,116.15,,,fee schedule,116.51% of cms physician fee schedule,356.33,48.48,,285.064,percent of total billed charges,48.48% of total billed charges,514.5,70,,411.6,percent of total billed charges,70% of total billed charges,514.5,70,,411.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,356.33,48.48,,285.064,percent of total billed charges,48.48% of total billed charges,661.5,90,,529.2,percent of total billed charges,90% of total billed charges,48.48,661.5,
US LIMITED or FOLLOW UP  PELVIS,42002150,CDM,402,RC,76857,HCPCS,outpatient,,,281,168.60,TC,168.6,60,,134.88,percent of total billed charges,60% of total billed charges,134.88,48,,107.904,percent of total billed charges,48% of total billed charges,119.75,100,,,fee schedule,100% of bcbs custom fee schedule,119.75,100,,,fee schedule,100% of bcbs custom fee schedule,132.92,111,,,fee schedule,111% of bcbs custom fee schedule,140.5,50,,112.4,percent of total billed charges,50% of total billed charges,196.7,70,,157.36,percent of total billed charges,70% of total billed charges,136.23,48.48,,108.984,percent of total billed charges,48.48% of total billed charges,52.83,116.15,,,fee schedule,116.51% of cms physician fee schedule,136.23,48.48,,108.984,percent of total billed charges,48.48% of total billed charges,196.7,70,,157.36,percent of total billed charges,70% of total billed charges,196.7,70,,157.36,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,136.23,48.48,,108.984,percent of total billed charges,48.48% of total billed charges,252.9,90,,202.32,percent of total billed charges,90% of total billed charges,48.48,252.9,
US OB <14 WKS MULTIPLE,42002237,CDM,402,RC,76802,HCPCS,outpatient,,,386,231.60,TC,231.6,60,,185.28,percent of total billed charges,60% of total billed charges,185.28,48,,148.224,percent of total billed charges,48% of total billed charges,87.73,100,,,fee schedule,100% of bcbs custom fee schedule,87.73,100,,,fee schedule,100% of bcbs custom fee schedule,97.38,111,,,fee schedule,111% of bcbs custom fee schedule,193,50,,154.4,percent of total billed charges,50% of total billed charges,270.2,70,,216.16,percent of total billed charges,70% of total billed charges,187.13,48.48,,149.704,percent of total billed charges,48.48% of total billed charges,65.25,116.15,,,fee schedule,116.51% of cms physician fee schedule,187.13,48.48,,149.704,percent of total billed charges,48.48% of total billed charges,270.2,70,,216.16,percent of total billed charges,70% of total billed charges,270.2,70,,216.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,187.13,48.48,,149.704,percent of total billed charges,48.48% of total billed charges,347.4,90,,277.92,percent of total billed charges,90% of total billed charges,48.48,347.4,
US BREAST LT LIMITED UNILAT,42001083,CDM,402,RC,76642,HCPCS,outpatient,,,525,315.00,TC,315,60,,252,percent of total billed charges,60% of total billed charges,252,48,,201.6,percent of total billed charges,48% of total billed charges,87.73,100,,,fee schedule,100% of bcbs custom fee schedule,87.73,100,,,fee schedule,100% of bcbs custom fee schedule,97.38,111,,,fee schedule,111% of bcbs custom fee schedule,262.5,50,,210,percent of total billed charges,50% of total billed charges,367.5,70,,294,percent of total billed charges,70% of total billed charges,254.52,48.48,,203.616,percent of total billed charges,48.48% of total billed charges,90.14,116.15,,,fee schedule,116.51% of cms physician fee schedule,254.52,48.48,,203.616,percent of total billed charges,48.48% of total billed charges,367.5,70,,294,percent of total billed charges,70% of total billed charges,367.5,70,,294,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,254.52,48.48,,203.616,percent of total billed charges,48.48% of total billed charges,472.5,90,,378,percent of total billed charges,90% of total billed charges,48.48,472.5,
US BREAST RT LIMITED UNILAT,42001083,CDM,402,RC,76642,HCPCS,outpatient,,,525,315.00,TC,315,60,,252,percent of total billed charges,60% of total billed charges,252,48,,201.6,percent of total billed charges,48% of total billed charges,87.73,100,,,fee schedule,100% of bcbs custom fee schedule,87.73,100,,,fee schedule,100% of bcbs custom fee schedule,97.38,111,,,fee schedule,111% of bcbs custom fee schedule,262.5,50,,210,percent of total billed charges,50% of total billed charges,367.5,70,,294,percent of total billed charges,70% of total billed charges,254.52,48.48,,203.616,percent of total billed charges,48.48% of total billed charges,90.14,116.15,,,fee schedule,116.51% of cms physician fee schedule,254.52,48.48,,203.616,percent of total billed charges,48.48% of total billed charges,367.5,70,,294,percent of total billed charges,70% of total billed charges,367.5,70,,294,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,254.52,48.48,,203.616,percent of total billed charges,48.48% of total billed charges,472.5,90,,378,percent of total billed charges,90% of total billed charges,48.48,472.5,
US ABDOMEN COMPLETE,36000030,CDM,402,RC,76700,HCPCS,outpatient,,,729,437.40,TC,437.4,60,,349.92,percent of total billed charges,60% of total billed charges,349.92,48,,279.936,percent of total billed charges,48% of total billed charges,148.43,100,,,fee schedule,100% of bcbs custom fee schedule,148.43,100,,,fee schedule,100% of bcbs custom fee schedule,164.76,111,,,fee schedule,111% of bcbs custom fee schedule,364.5,50,,291.6,percent of total billed charges,50% of total billed charges,510.3,70,,408.24,percent of total billed charges,70% of total billed charges,353.42,48.48,,282.736,percent of total billed charges,48.48% of total billed charges,122.7,116.15,,,fee schedule,116.51% of cms physician fee schedule,353.42,48.48,,282.736,percent of total billed charges,48.48% of total billed charges,510.3,70,,408.24,percent of total billed charges,70% of total billed charges,510.3,70,,408.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,353.42,48.48,,282.736,percent of total billed charges,48.48% of total billed charges,656.1,90,,524.88,percent of total billed charges,90% of total billed charges,48.48,656.1,
US CHEST,36000029,CDM,402,RC,76604,HCPCS,outpatient,,,523,313.80,TC,313.8,60,,251.04,percent of total billed charges,60% of total billed charges,251.04,48,,200.832,percent of total billed charges,48% of total billed charges,140.33,100,,,fee schedule,100% of bcbs custom fee schedule,140.33,100,,,fee schedule,100% of bcbs custom fee schedule,155.77,111,,,fee schedule,111% of bcbs custom fee schedule,261.5,50,,209.2,percent of total billed charges,50% of total billed charges,366.1,70,,292.88,percent of total billed charges,70% of total billed charges,253.55,48.48,,202.84,percent of total billed charges,48.48% of total billed charges,61.15,116.15,,,fee schedule,116.51% of cms physician fee schedule,253.55,48.48,,202.84,percent of total billed charges,48.48% of total billed charges,366.1,70,,292.88,percent of total billed charges,70% of total billed charges,366.1,70,,292.88,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,253.55,48.48,,202.84,percent of total billed charges,48.48% of total billed charges,470.7,90,,376.56,percent of total billed charges,90% of total billed charges,48.48,470.7,
US EXTREMITY NONVASCULAR COMPLETE,,,402,RC,76881,HCPCS,outpatient,,,685,411.00,,411,60,,328.8,percent of total billed charges,60% of total billed charges,328.8,48,,263.04,percent of total billed charges,48% of total billed charges,162.54,100,,,fee schedule,100% of bcbs custom fee schedule,162.54,100,,,fee schedule,100% of bcbs custom fee schedule,180.42,111,,,fee schedule,111% of bcbs custom fee schedule,342.5,50,,274,percent of total billed charges,50% of total billed charges,479.5,70,,383.6,percent of total billed charges,70% of total billed charges,332.09,48.48,,265.672,percent of total billed charges,48.48% of total billed charges,59.35,116.15,,,fee schedule,116.51% of cms physician fee schedule,332.09,48.48,,265.672,percent of total billed charges,48.48% of total billed charges,479.5,70,,383.6,percent of total billed charges,70% of total billed charges,479.5,70,,383.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,332.09,48.48,,265.672,percent of total billed charges,48.48% of total billed charges,616.5,90,,493.2,percent of total billed charges,90% of total billed charges,48.48,616.5,
"US LIMITED,EXTREMITY NONVASCULAR",42002075,CDM,402,RC,76882,HCPCS,outpatient,,,250,150.00,TC,150,60,,120,percent of total billed charges,60% of total billed charges,120,48,,96,percent of total billed charges,48% of total billed charges,19.08,100,,,fee schedule,100% of bcbs custom fee schedule,19.08,100,,,fee schedule,100% of bcbs custom fee schedule,21.18,111,,,fee schedule,111% of bcbs custom fee schedule,125,50,,100,percent of total billed charges,50% of total billed charges,175,70,,140,percent of total billed charges,70% of total billed charges,121.2,48.48,,96.96,percent of total billed charges,48.48% of total billed charges,68.17,116.15,,,fee schedule,116.51% of cms physician fee schedule,121.2,48.48,,96.96,percent of total billed charges,48.48% of total billed charges,175,70,,140,percent of total billed charges,70% of total billed charges,175,70,,140,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,121.2,48.48,,96.96,percent of total billed charges,48.48% of total billed charges,225,90,,180,percent of total billed charges,90% of total billed charges,48.48,225,
US ABD LMTD SINGLE ORGAN,36000031,CDM,402,RC,76705,HCPCS,outpatient,,,542,325.20,TC,325.2,60,,260.16,percent of total billed charges,60% of total billed charges,260.16,48,,208.128,percent of total billed charges,48% of total billed charges,140.33,100,,,fee schedule,100% of bcbs custom fee schedule,140.33,100,,,fee schedule,100% of bcbs custom fee schedule,155.77,111,,,fee schedule,111% of bcbs custom fee schedule,271,50,,216.8,percent of total billed charges,50% of total billed charges,379.4,70,,303.52,percent of total billed charges,70% of total billed charges,262.76,48.48,,210.208,percent of total billed charges,48.48% of total billed charges,91.63,116.15,,,fee schedule,116.51% of cms physician fee schedule,262.76,48.48,,210.208,percent of total billed charges,48.48% of total billed charges,379.4,70,,303.52,percent of total billed charges,70% of total billed charges,379.4,70,,303.52,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,262.76,48.48,,210.208,percent of total billed charges,48.48% of total billed charges,487.8,90,,390.24,percent of total billed charges,90% of total billed charges,48.48,487.8,
OB US >/=14 WKS SINGLE,42002180,CDM,402,RC,76805,HCPCS,outpatient,,,844,506.40,TC,506.4,60,,405.12,percent of total billed charges,60% of total billed charges,405.12,48,,324.096,percent of total billed charges,48% of total billed charges,158.46,100,,,fee schedule,100% of bcbs custom fee schedule,158.46,100,,,fee schedule,100% of bcbs custom fee schedule,175.89,111,,,fee schedule,111% of bcbs custom fee schedule,422,50,,337.6,percent of total billed charges,50% of total billed charges,590.8,70,,472.64,percent of total billed charges,70% of total billed charges,409.17,48.48,,327.336,percent of total billed charges,48.48% of total billed charges,143.21,116.15,,,fee schedule,116.51% of cms physician fee schedule,409.17,48.48,,327.336,percent of total billed charges,48.48% of total billed charges,590.8,70,,472.64,percent of total billed charges,70% of total billed charges,590.8,70,,472.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,409.17,48.48,,327.336,percent of total billed charges,48.48% of total billed charges,759.6,90,,607.68,percent of total billed charges,90% of total billed charges,48.48,759.6,
US TRANSVAG  OBS LIMITED,42002235,CDM,402,RC,76817,HCPCS,outpatient,,,580,348.00,TC,348,60,,278.4,percent of total billed charges,60% of total billed charges,278.4,48,,222.72,percent of total billed charges,48% of total billed charges,140.33,100,,,fee schedule,100% of bcbs custom fee schedule,140.33,100,,,fee schedule,100% of bcbs custom fee schedule,155.77,111,,,fee schedule,111% of bcbs custom fee schedule,290,50,,232,percent of total billed charges,50% of total billed charges,406,70,,324.8,percent of total billed charges,70% of total billed charges,281.18,48.48,,224.944,percent of total billed charges,48.48% of total billed charges,98.16,116.15,,,fee schedule,116.51% of cms physician fee schedule,281.18,48.48,,224.944,percent of total billed charges,48.48% of total billed charges,406,70,,324.8,percent of total billed charges,70% of total billed charges,406,70,,324.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,281.18,48.48,,224.944,percent of total billed charges,48.48% of total billed charges,522,90,,417.6,percent of total billed charges,90% of total billed charges,48.48,522,
US EXTRACRANIAL  BILAT Carotid,42001048,CDM,921,RC,93880,HCPCS,outpatient,,,1156,693.60,TC,693.6,60,,554.88,percent of total billed charges,60% of total billed charges,554.88,48,,443.904,percent of total billed charges,48% of total billed charges,334.45,100,,,fee schedule,100% of bcbs custom fee schedule,334.45,100,,,fee schedule,100% of bcbs custom fee schedule,371.24,111,,,fee schedule,111% of bcbs custom fee schedule,578,50,,462.4,percent of total billed charges,50% of total billed charges,809.2,70,,647.36,percent of total billed charges,70% of total billed charges,560.43,48.48,,448.344,percent of total billed charges,48.48% of total billed charges,197.92,116.15,,,fee schedule,116.51% of cms physician fee schedule,560.43,48.48,,448.344,percent of total billed charges,48.48% of total billed charges,809.2,70,,647.36,percent of total billed charges,70% of total billed charges,809.2,70,,647.36,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,560.43,48.48,,448.344,percent of total billed charges,48.48% of total billed charges,1040.4,90,,832.32,percent of total billed charges,90% of total billed charges,48.48,1040.4,
US EXTRACRANIAL LT,43502074,CDM,921,RC,93882,HCPCS,outpatient,,,771,462.60,TC,462.6,60,,370.08,percent of total billed charges,60% of total billed charges,370.08,48,,296.064,percent of total billed charges,48% of total billed charges,334.45,100,,,fee schedule,100% of bcbs custom fee schedule,334.45,100,,,fee schedule,100% of bcbs custom fee schedule,371.24,111,,,fee schedule,111% of bcbs custom fee schedule,385.5,50,,308.4,percent of total billed charges,50% of total billed charges,539.7,70,,431.76,percent of total billed charges,70% of total billed charges,373.78,48.48,,299.024,percent of total billed charges,48.48% of total billed charges,129.89,116.15,,,fee schedule,116.51% of cms physician fee schedule,373.78,48.48,,299.024,percent of total billed charges,48.48% of total billed charges,539.7,70,,431.76,percent of total billed charges,70% of total billed charges,539.7,70,,431.76,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,373.78,48.48,,299.024,percent of total billed charges,48.48% of total billed charges,693.9,90,,555.12,percent of total billed charges,90% of total billed charges,48.48,693.9,
US EXTRANCRANIAL RT,43502074,CDM,921,RC,93882,HCPCS,outpatient,,,771,462.60,TC,462.6,60,,370.08,percent of total billed charges,60% of total billed charges,370.08,48,,296.064,percent of total billed charges,48% of total billed charges,334.45,100,,,fee schedule,100% of bcbs custom fee schedule,334.45,100,,,fee schedule,100% of bcbs custom fee schedule,371.24,111,,,fee schedule,111% of bcbs custom fee schedule,385.5,50,,308.4,percent of total billed charges,50% of total billed charges,539.7,70,,431.76,percent of total billed charges,70% of total billed charges,373.78,48.48,,299.024,percent of total billed charges,48.48% of total billed charges,129.89,116.15,,,fee schedule,116.51% of cms physician fee schedule,373.78,48.48,,299.024,percent of total billed charges,48.48% of total billed charges,539.7,70,,431.76,percent of total billed charges,70% of total billed charges,539.7,70,,431.76,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,373.78,48.48,,299.024,percent of total billed charges,48.48% of total billed charges,693.9,90,,555.12,percent of total billed charges,90% of total billed charges,48.48,693.9,
ART FLOW UNILAT RT UPPER EXT,42001053,CDM,921,RC,93931,HCPCS,outpatient,,,529,317.40,TC,317.4,60,,253.92,percent of total billed charges,60% of total billed charges,253.92,48,,203.136,percent of total billed charges,48% of total billed charges,207.97,100,,,fee schedule,100% of bcbs custom fee schedule,207.97,100,,,fee schedule,100% of bcbs custom fee schedule,230.85,111,,,fee schedule,111% of bcbs custom fee schedule,264.5,50,,211.6,percent of total billed charges,50% of total billed charges,370.3,70,,296.24,percent of total billed charges,70% of total billed charges,256.46,48.48,,205.168,percent of total billed charges,48.48% of total billed charges,128.78,116.15,,,fee schedule,116.51% of cms physician fee schedule,256.46,48.48,,205.168,percent of total billed charges,48.48% of total billed charges,370.3,70,,296.24,percent of total billed charges,70% of total billed charges,370.3,70,,296.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,256.46,48.48,,205.168,percent of total billed charges,48.48% of total billed charges,476.1,90,,380.88,percent of total billed charges,90% of total billed charges,48.48,476.1,
ART FLOW UNILAT LT LWR EXT,42001055,CDM,921,RC,93926,HCPCS,outpatient,,,529,317.40,TC,317.4,60,,253.92,percent of total billed charges,60% of total billed charges,253.92,48,,203.136,percent of total billed charges,48% of total billed charges,207.97,100,,,fee schedule,100% of bcbs custom fee schedule,207.97,100,,,fee schedule,100% of bcbs custom fee schedule,230.85,111,,,fee schedule,111% of bcbs custom fee schedule,264.5,50,,211.6,percent of total billed charges,50% of total billed charges,370.3,70,,296.24,percent of total billed charges,70% of total billed charges,256.46,48.48,,205.168,percent of total billed charges,48.48% of total billed charges,149.53,116.15,,,fee schedule,116.51% of cms physician fee schedule,256.46,48.48,,205.168,percent of total billed charges,48.48% of total billed charges,370.3,70,,296.24,percent of total billed charges,70% of total billed charges,370.3,70,,296.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,256.46,48.48,,205.168,percent of total billed charges,48.48% of total billed charges,476.1,90,,380.88,percent of total billed charges,90% of total billed charges,48.48,476.1,
ART FLOW BI COMP UPR EXT w/ ABI,43509006,CDM,921,RC,93923,HCPCS,outpatient,,,823,493.80,TC,493.8,60,,395.04,percent of total billed charges,60% of total billed charges,395.04,48,,316.032,percent of total billed charges,48% of total billed charges,209.77,100,,,fee schedule,100% of bcbs custom fee schedule,209.77,100,,,fee schedule,100% of bcbs custom fee schedule,232.84,111,,,fee schedule,111% of bcbs custom fee schedule,411.5,50,,329.2,percent of total billed charges,50% of total billed charges,576.1,70,,460.88,percent of total billed charges,70% of total billed charges,398.99,48.48,,319.192,percent of total billed charges,48.48% of total billed charges,135.51,116.15,,,fee schedule,116.51% of cms physician fee schedule,398.99,48.48,,319.192,percent of total billed charges,48.48% of total billed charges,576.1,70,,460.88,percent of total billed charges,70% of total billed charges,576.1,70,,460.88,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,398.99,48.48,,319.192,percent of total billed charges,48.48% of total billed charges,740.7,90,,592.56,percent of total billed charges,90% of total billed charges,48.48,740.7,
ART FLOW BI COMP LWR EXT W/ ABI,43509006,CDM,921,RC,93923,HCPCS,outpatient,,,823,493.80,TC,493.8,60,,395.04,percent of total billed charges,60% of total billed charges,395.04,48,,316.032,percent of total billed charges,48% of total billed charges,209.77,100,,,fee schedule,100% of bcbs custom fee schedule,209.77,100,,,fee schedule,100% of bcbs custom fee schedule,232.84,111,,,fee schedule,111% of bcbs custom fee schedule,411.5,50,,329.2,percent of total billed charges,50% of total billed charges,576.1,70,,460.88,percent of total billed charges,70% of total billed charges,398.99,48.48,,319.192,percent of total billed charges,48.48% of total billed charges,135.51,116.15,,,fee schedule,116.51% of cms physician fee schedule,398.99,48.48,,319.192,percent of total billed charges,48.48% of total billed charges,576.1,70,,460.88,percent of total billed charges,70% of total billed charges,576.1,70,,460.88,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,398.99,48.48,,319.192,percent of total billed charges,48.48% of total billed charges,740.7,90,,592.56,percent of total billed charges,90% of total billed charges,48.48,740.7,
DOPPLER VENOUS COMP BILAT,42001059,CDM,921,RC,93970,HCPCS,outpatient,,,1074,644.40,TC,644.4,60,,515.52,percent of total billed charges,60% of total billed charges,515.52,48,,412.416,percent of total billed charges,48% of total billed charges,334.45,100,,,fee schedule,100% of bcbs custom fee schedule,334.45,100,,,fee schedule,100% of bcbs custom fee schedule,371.24,111,,,fee schedule,111% of bcbs custom fee schedule,537,50,,429.6,percent of total billed charges,50% of total billed charges,751.8,70,,601.44,percent of total billed charges,70% of total billed charges,520.68,48.48,,416.544,percent of total billed charges,48.48% of total billed charges,194.28,116.15,,,fee schedule,116.51% of cms physician fee schedule,520.68,48.48,,416.544,percent of total billed charges,48.48% of total billed charges,751.8,70,,601.44,percent of total billed charges,70% of total billed charges,751.8,70,,601.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,520.68,48.48,,416.544,percent of total billed charges,48.48% of total billed charges,966.6,90,,773.28,percent of total billed charges,90% of total billed charges,48.48,966.6,
DOPPLER VENOUS UNILAT RT,42001049,CDM,921,RC,93971,HCPCS,outpatient,,,716,429.60,TC,429.6,60,,343.68,percent of total billed charges,60% of total billed charges,343.68,48,,274.944,percent of total billed charges,48% of total billed charges,207.97,100,,,fee schedule,100% of bcbs custom fee schedule,207.97,100,,,fee schedule,100% of bcbs custom fee schedule,230.85,111,,,fee schedule,111% of bcbs custom fee schedule,358,50,,286.4,percent of total billed charges,50% of total billed charges,501.2,70,,400.96,percent of total billed charges,70% of total billed charges,347.12,48.48,,277.696,percent of total billed charges,48.48% of total billed charges,123.58,116.15,,,fee schedule,116.51% of cms physician fee schedule,347.12,48.48,,277.696,percent of total billed charges,48.48% of total billed charges,501.2,70,,400.96,percent of total billed charges,70% of total billed charges,501.2,70,,400.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,347.12,48.48,,277.696,percent of total billed charges,48.48% of total billed charges,644.4,90,,515.52,percent of total billed charges,90% of total billed charges,48.48,644.4,
DOPPLER VEN UNILAT LT,42001049,CDM,921,RC,93971,HCPCS,outpatient,,,716,429.60,TC,429.6,60,,343.68,percent of total billed charges,60% of total billed charges,343.68,48,,274.944,percent of total billed charges,48% of total billed charges,207.97,100,,,fee schedule,100% of bcbs custom fee schedule,207.97,100,,,fee schedule,100% of bcbs custom fee schedule,230.85,111,,,fee schedule,111% of bcbs custom fee schedule,358,50,,286.4,percent of total billed charges,50% of total billed charges,501.2,70,,400.96,percent of total billed charges,70% of total billed charges,347.12,48.48,,277.696,percent of total billed charges,48.48% of total billed charges,123.58,116.15,,,fee schedule,116.51% of cms physician fee schedule,347.12,48.48,,277.696,percent of total billed charges,48.48% of total billed charges,501.2,70,,400.96,percent of total billed charges,70% of total billed charges,501.2,70,,400.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,347.12,48.48,,277.696,percent of total billed charges,48.48% of total billed charges,644.4,90,,515.52,percent of total billed charges,90% of total billed charges,48.48,644.4,
ART FLOW UNILAT LT UPPER EXT,42001053,CDM,921,RC,93931,HCPCS,outpatient,,,529,317.40,TC,317.4,60,,253.92,percent of total billed charges,60% of total billed charges,253.92,48,,203.136,percent of total billed charges,48% of total billed charges,207.97,100,,,fee schedule,100% of bcbs custom fee schedule,207.97,100,,,fee schedule,100% of bcbs custom fee schedule,230.85,111,,,fee schedule,111% of bcbs custom fee schedule,264.5,50,,211.6,percent of total billed charges,50% of total billed charges,370.3,70,,296.24,percent of total billed charges,70% of total billed charges,256.46,48.48,,205.168,percent of total billed charges,48.48% of total billed charges,128.78,116.15,,,fee schedule,116.51% of cms physician fee schedule,256.46,48.48,,205.168,percent of total billed charges,48.48% of total billed charges,370.3,70,,296.24,percent of total billed charges,70% of total billed charges,370.3,70,,296.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,256.46,48.48,,205.168,percent of total billed charges,48.48% of total billed charges,476.1,90,,380.88,percent of total billed charges,90% of total billed charges,48.48,476.1,
ART FLOW UNILAT RT LWR EXT,42001055,CDM,921,RC,93926,HCPCS,outpatient,,,529,317.40,TC,317.4,60,,253.92,percent of total billed charges,60% of total billed charges,253.92,48,,203.136,percent of total billed charges,48% of total billed charges,207.97,100,,,fee schedule,100% of bcbs custom fee schedule,207.97,100,,,fee schedule,100% of bcbs custom fee schedule,230.85,111,,,fee schedule,111% of bcbs custom fee schedule,264.5,50,,211.6,percent of total billed charges,50% of total billed charges,370.3,70,,296.24,percent of total billed charges,70% of total billed charges,256.46,48.48,,205.168,percent of total billed charges,48.48% of total billed charges,149.53,116.15,,,fee schedule,116.51% of cms physician fee schedule,256.46,48.48,,205.168,percent of total billed charges,48.48% of total billed charges,370.3,70,,296.24,percent of total billed charges,70% of total billed charges,370.3,70,,296.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,256.46,48.48,,205.168,percent of total billed charges,48.48% of total billed charges,476.1,90,,380.88,percent of total billed charges,90% of total billed charges,48.48,476.1,
DUPLEX LOWER EXT ARTERIES BILATERAL,42001062,CDM,921,RC,93925,HCPCS,outpatient,,,675,405.00,TC,405,60,,324,percent of total billed charges,60% of total billed charges,324,48,,259.2,percent of total billed charges,48% of total billed charges,334.45,100,,,fee schedule,100% of bcbs custom fee schedule,334.45,100,,,fee schedule,100% of bcbs custom fee schedule,371.24,111,,,fee schedule,111% of bcbs custom fee schedule,337.5,50,,270,percent of total billed charges,50% of total billed charges,472.5,70,,378,percent of total billed charges,70% of total billed charges,327.24,48.48,,261.792,percent of total billed charges,48.48% of total billed charges,249.16,116.15,,,fee schedule,116.51% of cms physician fee schedule,327.24,48.48,,261.792,percent of total billed charges,48.48% of total billed charges,472.5,70,,378,percent of total billed charges,70% of total billed charges,472.5,70,,378,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,327.24,48.48,,261.792,percent of total billed charges,48.48% of total billed charges,607.5,90,,486,percent of total billed charges,90% of total billed charges,48.48,607.5,
ARTERIAL DOPPLER BILATERAL UPPER EXTREMITY,42001061,CDM,921,RC,93930,HCPCS,outpatient,,,670,402.00,TC,402,60,,321.6,percent of total billed charges,60% of total billed charges,321.6,48,,257.28,percent of total billed charges,48% of total billed charges,334.45,100,,,fee schedule,100% of bcbs custom fee schedule,334.45,100,,,fee schedule,100% of bcbs custom fee schedule,371.24,111,,,fee schedule,111% of bcbs custom fee schedule,335,50,,268,percent of total billed charges,50% of total billed charges,469,70,,375.2,percent of total billed charges,70% of total billed charges,324.82,48.48,,259.856,percent of total billed charges,48.48% of total billed charges,206.15,116.15,,,fee schedule,116.51% of cms physician fee schedule,324.82,48.48,,259.856,percent of total billed charges,48.48% of total billed charges,469,70,,375.2,percent of total billed charges,70% of total billed charges,469,70,,375.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,324.82,48.48,,259.856,percent of total billed charges,48.48% of total billed charges,603,90,,482.4,percent of total billed charges,90% of total billed charges,48.48,603,
US ANKLE BRACHIAL INDE,43509017,CDM,921,RC,93922,HCPCS,outpatient,,,664,398.40,TC,398.4,60,,318.72,percent of total billed charges,60% of total billed charges,318.72,48,,254.976,percent of total billed charges,48% of total billed charges,209.77,100,,,fee schedule,100% of bcbs custom fee schedule,209.77,100,,,fee schedule,100% of bcbs custom fee schedule,232.84,111,,,fee schedule,111% of bcbs custom fee schedule,332,50,,265.6,percent of total billed charges,50% of total billed charges,464.8,70,,371.84,percent of total billed charges,70% of total billed charges,321.91,48.48,,257.528,percent of total billed charges,48.48% of total billed charges,85.37,116.15,,,fee schedule,116.51% of cms physician fee schedule,321.91,48.48,,257.528,percent of total billed charges,48.48% of total billed charges,464.8,70,,371.84,percent of total billed charges,70% of total billed charges,464.8,70,,371.84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,321.91,48.48,,257.528,percent of total billed charges,48.48% of total billed charges,597.6,90,,478.08,percent of total billed charges,90% of total billed charges,48.48,597.6,
US PANCREAS LIMITED,36000031,CDM,402,RC,76705,HCPCS,outpatient,,,542,325.20,TC,325.2,60,,260.16,percent of total billed charges,60% of total billed charges,260.16,48,,208.128,percent of total billed charges,48% of total billed charges,140.33,100,,,fee schedule,100% of bcbs custom fee schedule,140.33,100,,,fee schedule,100% of bcbs custom fee schedule,155.77,111,,,fee schedule,111% of bcbs custom fee schedule,271,50,,216.8,percent of total billed charges,50% of total billed charges,379.4,70,,303.52,percent of total billed charges,70% of total billed charges,262.76,48.48,,210.208,percent of total billed charges,48.48% of total billed charges,91.63,116.15,,,fee schedule,116.51% of cms physician fee schedule,262.76,48.48,,210.208,percent of total billed charges,48.48% of total billed charges,379.4,70,,303.52,percent of total billed charges,70% of total billed charges,379.4,70,,303.52,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,262.76,48.48,,210.208,percent of total billed charges,48.48% of total billed charges,487.8,90,,390.24,percent of total billed charges,90% of total billed charges,48.48,487.8,
US SCROTUM,36000038,CDM,402,RC,76870,HCPCS,outpatient,,,401,240.60,TC,240.6,60,,192.48,percent of total billed charges,60% of total billed charges,192.48,48,,153.984,percent of total billed charges,48% of total billed charges,140.33,100,,,fee schedule,100% of bcbs custom fee schedule,140.33,100,,,fee schedule,100% of bcbs custom fee schedule,155.77,111,,,fee schedule,111% of bcbs custom fee schedule,200.5,50,,160.4,percent of total billed charges,50% of total billed charges,280.7,70,,224.56,percent of total billed charges,70% of total billed charges,194.4,48.48,,155.52,percent of total billed charges,48.48% of total billed charges,105.08,116.15,,,fee schedule,116.51% of cms physician fee schedule,194.4,48.48,,155.52,percent of total billed charges,48.48% of total billed charges,280.7,70,,224.56,percent of total billed charges,70% of total billed charges,280.7,70,,224.56,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,194.4,48.48,,155.52,percent of total billed charges,48.48% of total billed charges,360.9,90,,288.72,percent of total billed charges,90% of total billed charges,48.48,360.9,
US SPLEEN,36000031,CDM,402,RC,76705,HCPCS,outpatient,,,542,325.20,TC,325.2,60,,260.16,percent of total billed charges,60% of total billed charges,260.16,48,,208.128,percent of total billed charges,48% of total billed charges,140.33,100,,,fee schedule,100% of bcbs custom fee schedule,140.33,100,,,fee schedule,100% of bcbs custom fee schedule,155.77,111,,,fee schedule,111% of bcbs custom fee schedule,271,50,,216.8,percent of total billed charges,50% of total billed charges,379.4,70,,303.52,percent of total billed charges,70% of total billed charges,262.76,48.48,,210.208,percent of total billed charges,48.48% of total billed charges,91.63,116.15,,,fee schedule,116.51% of cms physician fee schedule,262.76,48.48,,210.208,percent of total billed charges,48.48% of total billed charges,379.4,70,,303.52,percent of total billed charges,70% of total billed charges,379.4,70,,303.52,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,262.76,48.48,,210.208,percent of total billed charges,48.48% of total billed charges,487.8,90,,390.24,percent of total billed charges,90% of total billed charges,48.48,487.8,
US SOFT TISSUES HEAD NECK THYROID,42002220,CDM,402,RC,76536,HCPCS,outpatient,,,689,413.40,TC,413.4,60,,330.72,percent of total billed charges,60% of total billed charges,330.72,48,,264.576,percent of total billed charges,48% of total billed charges,140.33,100,,,fee schedule,100% of bcbs custom fee schedule,140.33,100,,,fee schedule,100% of bcbs custom fee schedule,155.77,111,,,fee schedule,111% of bcbs custom fee schedule,344.5,50,,275.6,percent of total billed charges,50% of total billed charges,482.3,70,,385.84,percent of total billed charges,70% of total billed charges,334.03,48.48,,267.224,percent of total billed charges,48.48% of total billed charges,115.2,116.15,,,fee schedule,116.51% of cms physician fee schedule,334.03,48.48,,267.224,percent of total billed charges,48.48% of total billed charges,482.3,70,,385.84,percent of total billed charges,70% of total billed charges,482.3,70,,385.84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,334.03,48.48,,267.224,percent of total billed charges,48.48% of total billed charges,620.1,90,,496.08,percent of total billed charges,90% of total billed charges,48.48,620.1,
US PELVIC COMPLETE,36000036,CDM,402,RC,76856,HCPCS,outpatient,,,653,391.80,TC,391.8,60,,313.44,percent of total billed charges,60% of total billed charges,313.44,48,,250.752,percent of total billed charges,48% of total billed charges,140.33,100,,,fee schedule,100% of bcbs custom fee schedule,140.33,100,,,fee schedule,100% of bcbs custom fee schedule,155.77,111,,,fee schedule,111% of bcbs custom fee schedule,326.5,50,,261.2,percent of total billed charges,50% of total billed charges,457.1,70,,365.68,percent of total billed charges,70% of total billed charges,316.57,48.48,,253.256,percent of total billed charges,48.48% of total billed charges,110.75,116.15,,,fee schedule,116.51% of cms physician fee schedule,316.57,48.48,,253.256,percent of total billed charges,48.48% of total billed charges,457.1,70,,365.68,percent of total billed charges,70% of total billed charges,457.1,70,,365.68,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,316.57,48.48,,253.256,percent of total billed charges,48.48% of total billed charges,587.7,90,,470.16,percent of total billed charges,90% of total billed charges,48.48,587.7,
US RENAL AND BLADDER,36000032,CDM,402,RC,76770,HCPCS,outpatient,,,672,403.20,TC,403.2,60,,322.56,percent of total billed charges,60% of total billed charges,322.56,48,,258.048,percent of total billed charges,48% of total billed charges,148.43,100,,,fee schedule,100% of bcbs custom fee schedule,148.43,100,,,fee schedule,100% of bcbs custom fee schedule,164.76,111,,,fee schedule,111% of bcbs custom fee schedule,336,50,,268.8,percent of total billed charges,50% of total billed charges,470.4,70,,376.32,percent of total billed charges,70% of total billed charges,325.79,48.48,,260.632,percent of total billed charges,48.48% of total billed charges,114.14,116.15,,,fee schedule,116.51% of cms physician fee schedule,325.79,48.48,,260.632,percent of total billed charges,48.48% of total billed charges,470.4,70,,376.32,percent of total billed charges,70% of total billed charges,470.4,70,,376.32,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,325.79,48.48,,260.632,percent of total billed charges,48.48% of total billed charges,604.8,90,,483.84,percent of total billed charges,90% of total billed charges,48.48,604.8,
US LIVER,36000031,CDM,402,RC,76705,HCPCS,outpatient,,,542,325.20,TC,325.2,60,,260.16,percent of total billed charges,60% of total billed charges,260.16,48,,208.128,percent of total billed charges,48% of total billed charges,140.33,100,,,fee schedule,100% of bcbs custom fee schedule,140.33,100,,,fee schedule,100% of bcbs custom fee schedule,155.77,111,,,fee schedule,111% of bcbs custom fee schedule,271,50,,216.8,percent of total billed charges,50% of total billed charges,379.4,70,,303.52,percent of total billed charges,70% of total billed charges,262.76,48.48,,210.208,percent of total billed charges,48.48% of total billed charges,91.63,116.15,,,fee schedule,116.51% of cms physician fee schedule,262.76,48.48,,210.208,percent of total billed charges,48.48% of total billed charges,379.4,70,,303.52,percent of total billed charges,70% of total billed charges,379.4,70,,303.52,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,262.76,48.48,,210.208,percent of total billed charges,48.48% of total billed charges,487.8,90,,390.24,percent of total billed charges,90% of total billed charges,48.48,487.8,
US BREAST RT COMPLETE,42001081,CDM,402,RC,76641,HCPCS,outpatient,,,638,382.80,TC,382.8,60,,306.24,percent of total billed charges,60% of total billed charges,306.24,48,,244.992,percent of total billed charges,48% of total billed charges,87.73,100,,,fee schedule,100% of bcbs custom fee schedule,87.73,100,,,fee schedule,100% of bcbs custom fee schedule,97.38,111,,,fee schedule,111% of bcbs custom fee schedule,319,50,,255.2,percent of total billed charges,50% of total billed charges,446.6,70,,357.28,percent of total billed charges,70% of total billed charges,309.3,48.48,,247.44,percent of total billed charges,48.48% of total billed charges,108.33,116.15,,,fee schedule,116.51% of cms physician fee schedule,309.3,48.48,,247.44,percent of total billed charges,48.48% of total billed charges,446.6,70,,357.28,percent of total billed charges,70% of total billed charges,446.6,70,,357.28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,309.3,48.48,,247.44,percent of total billed charges,48.48% of total billed charges,574.2,90,,459.36,percent of total billed charges,90% of total billed charges,48.48,574.2,
US BREAST LT COMPLETE,42001081,CDM,402,RC,76641,HCPCS,outpatient,,,638,382.80,TC,382.8,60,,306.24,percent of total billed charges,60% of total billed charges,306.24,48,,244.992,percent of total billed charges,48% of total billed charges,87.73,100,,,fee schedule,100% of bcbs custom fee schedule,87.73,100,,,fee schedule,100% of bcbs custom fee schedule,97.38,111,,,fee schedule,111% of bcbs custom fee schedule,319,50,,255.2,percent of total billed charges,50% of total billed charges,446.6,70,,357.28,percent of total billed charges,70% of total billed charges,309.3,48.48,,247.44,percent of total billed charges,48.48% of total billed charges,108.33,116.15,,,fee schedule,116.51% of cms physician fee schedule,309.3,48.48,,247.44,percent of total billed charges,48.48% of total billed charges,446.6,70,,357.28,percent of total billed charges,70% of total billed charges,446.6,70,,357.28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,309.3,48.48,,247.44,percent of total billed charges,48.48% of total billed charges,574.2,90,,459.36,percent of total billed charges,90% of total billed charges,48.48,574.2,
ECHOCARDIOGRAM COMPLETE - GLOBAL CHG,43509012,CDM,483,RC,93306,HCPCS,outpatient,,,5074.42,3044.65,,3044.65,60,,2435.72,percent of total billed charges,60% of total billed charges,2435.72,48,,1948.576,percent of total billed charges,48% of total billed charges,949.1,100,,,fee schedule,100% of bcbs custom fee schedule,949.1,100,,,fee schedule,100% of bcbs custom fee schedule,1053.5,111,,,fee schedule,111% of bcbs custom fee schedule,2537.21,50,,2029.768,percent of total billed charges,50% of total billed charges,3552.09,70,,2841.672,percent of total billed charges,70% of total billed charges,2460.08,48.48,,1968.064,percent of total billed charges,48.48% of total billed charges,207.32,116.15,,,fee schedule,116.51% of cms physician fee schedule,2460.08,48.48,,1968.064,percent of total billed charges,48.48% of total billed charges,3552.09,70,,2841.672,percent of total billed charges,70% of total billed charges,3552.09,70,,2841.672,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,2460.08,48.48,,1968.064,percent of total billed charges,48.48% of total billed charges,4566.98,90,,3653.584,percent of total billed charges,90% of total billed charges,48.48,4566.98,
US INFANT HIPS,,,402,RC,76885,HCPCS,outpatient,,,865,519.00,TC,519,60,,415.2,percent of total billed charges,60% of total billed charges,415.2,48,,332.16,percent of total billed charges,48% of total billed charges,115.82,100,,,fee schedule,100% of bcbs custom fee schedule,115.82,100,,,fee schedule,100% of bcbs custom fee schedule,128.56,111,,,fee schedule,111% of bcbs custom fee schedule,432.5,50,,346,percent of total billed charges,50% of total billed charges,605.5,70,,484.4,percent of total billed charges,70% of total billed charges,419.35,48.48,,335.48,percent of total billed charges,48.48% of total billed charges,142.02,116.15,,,fee schedule,116.51% of cms physician fee schedule,419.35,48.48,,335.48,percent of total billed charges,48.48% of total billed charges,605.5,70,,484.4,percent of total billed charges,70% of total billed charges,605.5,70,,484.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,419.35,48.48,,335.48,percent of total billed charges,48.48% of total billed charges,778.5,90,,622.8,percent of total billed charges,90% of total billed charges,48.48,778.5,
TRANSVAGINALS US NONOB,42002230,CDM,402,RC,76830,HCPCS,outpatient,,,725,435.00,TC,435,60,,348,percent of total billed charges,60% of total billed charges,348,48,,278.4,percent of total billed charges,48% of total billed charges,140.33,100,,,fee schedule,100% of bcbs custom fee schedule,140.33,100,,,fee schedule,100% of bcbs custom fee schedule,155.77,111,,,fee schedule,111% of bcbs custom fee schedule,362.5,50,,290,percent of total billed charges,50% of total billed charges,507.5,70,,406,percent of total billed charges,70% of total billed charges,351.48,48.48,,281.184,percent of total billed charges,48.48% of total billed charges,125.07,116.15,,,fee schedule,116.51% of cms physician fee schedule,351.48,48.48,,281.184,percent of total billed charges,48.48% of total billed charges,507.5,70,,406,percent of total billed charges,70% of total billed charges,507.5,70,,406,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,351.48,48.48,,281.184,percent of total billed charges,48.48% of total billed charges,652.5,90,,522,percent of total billed charges,90% of total billed charges,48.48,652.5,
VASCULAR STUDY,43509066,CDM,921,RC,93976,HCPCS,outpatient,,,970,582.00,TC,582,60,,465.6,percent of total billed charges,60% of total billed charges,465.6,48,,372.48,percent of total billed charges,48% of total billed charges,334.45,100,,,fee schedule,100% of bcbs custom fee schedule,334.45,100,,,fee schedule,100% of bcbs custom fee schedule,371.24,111,,,fee schedule,111% of bcbs custom fee schedule,485,50,,388,percent of total billed charges,50% of total billed charges,679,70,,543.2,percent of total billed charges,70% of total billed charges,470.26,48.48,,376.208,percent of total billed charges,48.48% of total billed charges,165.77,116.15,,,fee schedule,116.51% of cms physician fee schedule,470.26,48.48,,376.208,percent of total billed charges,48.48% of total billed charges,679,70,,543.2,percent of total billed charges,70% of total billed charges,679,70,,543.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,470.26,48.48,,376.208,percent of total billed charges,48.48% of total billed charges,873,90,,698.4,percent of total billed charges,90% of total billed charges,48.48,873,
ECHO EXAM OF HEAD,,,402,RC,76506,HCPCS,outpatient,,,701,420.60,TC,420.6,60,,336.48,percent of total billed charges,60% of total billed charges,336.48,48,,269.184,percent of total billed charges,48% of total billed charges,107.05,100,,,fee schedule,100% of bcbs custom fee schedule,107.05,100,,,fee schedule,100% of bcbs custom fee schedule,118.83,111,,,fee schedule,111% of bcbs custom fee schedule,350.5,50,,280.4,percent of total billed charges,50% of total billed charges,490.7,70,,392.56,percent of total billed charges,70% of total billed charges,339.84,48.48,,271.872,percent of total billed charges,48.48% of total billed charges,118.55,116.15,,,fee schedule,116.51% of cms physician fee schedule,339.84,48.48,,271.872,percent of total billed charges,48.48% of total billed charges,490.7,70,,392.56,percent of total billed charges,70% of total billed charges,490.7,70,,392.56,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,339.84,48.48,,271.872,percent of total billed charges,48.48% of total billed charges,630.9,90,,504.72,percent of total billed charges,90% of total billed charges,48.48,630.9,
RADEX GI TRACT UPPER W/WO DELAYED IMAGES,,,324,RC,74240,HCPCS,outpatient,,,113.66,68.20,TC,68.2,60,,54.56,percent of total billed charges,60% of total billed charges,54.56,48,,43.648,percent of total billed charges,48% of total billed charges,129.81,100,,,fee schedule,100% of bcbs custom fee schedule,129.81,100,,,fee schedule,100% of bcbs custom fee schedule,144.09,111,,,fee schedule,111% of bcbs custom fee schedule,56.83,50,,45.464,percent of total billed charges,50% of total billed charges,79.56,70,,63.648,percent of total billed charges,70% of total billed charges,55.1,48.48,,44.08,percent of total billed charges,48.48% of total billed charges,128.98,116.15,,,fee schedule,116.51% of cms physician fee schedule,55.1,48.48,,44.08,percent of total billed charges,48.48% of total billed charges,79.56,70,,63.648,percent of total billed charges,70% of total billed charges,79.56,70,,63.648,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,55.1,48.48,,44.08,percent of total billed charges,48.48% of total billed charges,102.29,90,,81.832,percent of total billed charges,90% of total billed charges,48.48,102.29,
TETANUS/DIPTH VAC INJ 0.5ML,43601419,CDM,250,RC,90714,HCPCS,outpatient,1,UN,87,52.20,AT,52.2,60,,41.76,percent of total billed charges,60% of total billed charges,41.76,48,,33.408,percent of total billed charges,48% of total billed charges,27.8,100,,,fee schedule,100% of bcbs custom fee schedule,27.8,100,,,fee schedule,100% of bcbs custom fee schedule,30.86,111,,,fee schedule,111% of bcbs custom fee schedule,43.5,50,,34.8,percent of total billed charges,50% of total billed charges,60.9,70,,48.72,percent of total billed charges,70% of total billed charges,42.18,48.48,,33.744,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,42.18,48.48,,33.744,percent of total billed charges,48.48% of total billed charges,60.9,70,,48.72,percent of total billed charges,70% of total billed charges,60.9,70,,48.72,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,42.18,48.48,,33.744,percent of total billed charges,48.48% of total billed charges,78.3,90,,62.64,percent of total billed charges,90% of total billed charges,42.18,90,
INFLUENZA VACC INJ,,,636,RC,90656,HCPCS,outpatient,1,UN,40,24.00,,24,60,,19.2,percent of total billed charges,60% of total billed charges,19.2,48,,15.36,percent of total billed charges,48% of total billed charges,19.77,100,,,fee schedule,100% of bcbs custom fee schedule,19.77,100,,,fee schedule,100% of bcbs custom fee schedule,21.94,111,,,fee schedule,111% of bcbs custom fee schedule,20,50,,16,percent of total billed charges,50% of total billed charges,28,70,,22.4,percent of total billed charges,70% of total billed charges,19.39,48.48,,15.512,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,19.39,48.48,,15.512,percent of total billed charges,48.48% of total billed charges,28,70,,22.4,percent of total billed charges,70% of total billed charges,28,70,,22.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,19.39,48.48,,15.512,percent of total billed charges,48.48% of total billed charges,36,90,,28.8,percent of total billed charges,90% of total billed charges,19.39,90,
IMMUNIZATION ADMIN,32009071,CDM,771,RC,90471,HCPCS,outpatient,,,32,19.20,,19.2,60,,15.36,percent of total billed charges,60% of total billed charges,15.36,48,,12.288,percent of total billed charges,48% of total billed charges,19.31,100,,,fee schedule,100% of bcbs custom fee schedule,19.31,100,,,fee schedule,100% of bcbs custom fee schedule,21.43,111,,,fee schedule,111% of bcbs custom fee schedule,16,50,,12.8,percent of total billed charges,50% of total billed charges,22.4,70,,17.92,percent of total billed charges,70% of total billed charges,15.51,48.48,,12.408,percent of total billed charges,48.48% of total billed charges,21.92,116.15,,,fee schedule,116.51% of cms physician fee schedule,15.51,48.48,,12.408,percent of total billed charges,48.48% of total billed charges,22.4,70,,17.92,percent of total billed charges,70% of total billed charges,22.4,70,,17.92,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,15.51,48.48,,12.408,percent of total billed charges,48.48% of total billed charges,28.8,90,,23.04,percent of total billed charges,90% of total billed charges,15.51,90,
IMMUNIZATION ADMIN EA ADD,36009204,CDM,771,RC,90472,HCPCS,outpatient,,,32,19.20,,19.2,60,,15.36,percent of total billed charges,60% of total billed charges,15.36,48,,12.288,percent of total billed charges,48% of total billed charges,14.92,100,,,fee schedule,100% of bcbs custom fee schedule,14.92,100,,,fee schedule,100% of bcbs custom fee schedule,16.56,111,,,fee schedule,111% of bcbs custom fee schedule,16,50,,12.8,percent of total billed charges,50% of total billed charges,22.4,70,,17.92,percent of total billed charges,70% of total billed charges,15.51,48.48,,12.408,percent of total billed charges,48.48% of total billed charges,15.72,116.15,,,fee schedule,116.51% of cms physician fee schedule,15.51,48.48,,12.408,percent of total billed charges,48.48% of total billed charges,22.4,70,,17.92,percent of total billed charges,70% of total billed charges,22.4,70,,17.92,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,15.51,48.48,,12.408,percent of total billed charges,48.48% of total billed charges,28.8,90,,23.04,percent of total billed charges,90% of total billed charges,15.51,90,
NOC^ SOD CHLOR 0.9% VIAL 20ML,,,259,RC,A4216,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,0.45,100,,,fee schedule,100% of bcbs custom fee schedule,0.45,100,,,fee schedule,100% of bcbs custom fee schedule,0.5,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
VACC ADM INTRANAL/ORAL,,,771,RC,90473,HCPCS,outpatient,,,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,19.31,100,,,fee schedule,100% of bcbs custom fee schedule,19.31,100,,,fee schedule,100% of bcbs custom fee schedule,21.43,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,17.85,116.15,,,fee schedule,116.51% of cms physician fee schedule,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
INS- NPL/ INSULIN LISPRO,,,636,RC,J1815,HCPCS,outpatient,1,UN,24,14.40,,14.4,60,,11.52,percent of total billed charges,60% of total billed charges,11.52,48,,9.216,percent of total billed charges,48% of total billed charges,0.96,100,,,fee schedule,100% of bcbs custom fee schedule,0.96,100,,,fee schedule,100% of bcbs custom fee schedule,1.07,111,,,fee schedule,111% of bcbs custom fee schedule,12,50,,9.6,percent of total billed charges,50% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,21.6,90,,17.28,percent of total billed charges,90% of total billed charges,11.64,90,
INS- LISPRO INJ [100 UNT/,,,636,RC,J1815,HCPCS,outpatient,1,UN,24,14.40,,14.4,60,,11.52,percent of total billed charges,60% of total billed charges,11.52,48,,9.216,percent of total billed charges,48% of total billed charges,0.96,100,,,fee schedule,100% of bcbs custom fee schedule,0.96,100,,,fee schedule,100% of bcbs custom fee schedule,1.07,111,,,fee schedule,111% of bcbs custom fee schedule,12,50,,9.6,percent of total billed charges,50% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,21.6,90,,17.28,percent of total billed charges,90% of total billed charges,11.64,90,
INS- GLARGINE INJ [100 UN,,,636,RC,J1815,HCPCS,outpatient,1,UN,24,14.40,,14.4,60,,11.52,percent of total billed charges,60% of total billed charges,11.52,48,,9.216,percent of total billed charges,48% of total billed charges,0.96,100,,,fee schedule,100% of bcbs custom fee schedule,0.96,100,,,fee schedule,100% of bcbs custom fee schedule,1.07,111,,,fee schedule,111% of bcbs custom fee schedule,12,50,,9.6,percent of total billed charges,50% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,21.6,90,,17.28,percent of total billed charges,90% of total billed charges,11.64,90,
INS- ASPART MIX 70/30 100,,,636,RC,J1815,HCPCS,outpatient,1,UN,24,14.40,,14.4,60,,11.52,percent of total billed charges,60% of total billed charges,11.52,48,,9.216,percent of total billed charges,48% of total billed charges,0.96,100,,,fee schedule,100% of bcbs custom fee schedule,0.96,100,,,fee schedule,100% of bcbs custom fee schedule,1.07,111,,,fee schedule,111% of bcbs custom fee schedule,12,50,,9.6,percent of total billed charges,50% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,21.6,90,,17.28,percent of total billed charges,90% of total billed charges,11.64,90,
NOC^ EMOLLIENT OIN,,,257,RC,J3490,HCPCS,outpatient,1,UN,16,9.60,,9.6,60,,7.68,percent of total billed charges,60% of total billed charges,7.68,48,,6.144,percent of total billed charges,48% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,11.2,70,,8.96,percent of total billed charges,70% of total billed charges,7.76,48.48,,6.208,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,7.76,48.48,,6.208,percent of total billed charges,48.48% of total billed charges,11.2,70,,8.96,percent of total billed charges,70% of total billed charges,11.2,70,,8.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,7.76,48.48,,6.208,percent of total billed charges,48.48% of total billed charges,14.4,90,,11.52,percent of total billed charges,90% of total billed charges,7.76,90,
NOC^ QUINAPRIL TAB [10 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,24,14.40,,14.4,60,,11.52,percent of total billed charges,60% of total billed charges,11.52,48,,9.216,percent of total billed charges,48% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,21.6,90,,17.28,percent of total billed charges,90% of total billed charges,11.64,90,
NOC^ QUINAPRIL TAB [20 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,24,14.40,,14.4,60,,11.52,percent of total billed charges,60% of total billed charges,11.52,48,,9.216,percent of total billed charges,48% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,21.6,90,,17.28,percent of total billed charges,90% of total billed charges,11.64,90,
ACCUZYME OINT 30GM,,,259,RC,,,outpatient,,,121,72.60,,72.6,60,,58.08,percent of total billed charges,60% of total billed charges,58.08,48,,46.464,percent of total billed charges,48% of total billed charges,60.5,50,,48.4,percent of total billed charges,50% of total billed charges,60.5,50,,48.4,percent of total billed charges,50% of total billed charges,60.5,50,,48.4,percent of total billed charges,50% of total billed charges,60.5,50,,48.4,percent of total billed charges,50% of total billed charges,84.7,70,,67.76,percent of total billed charges,70% of total billed charges,58.66,48.48,,46.928,percent of total billed charges,48.48% of total billed charges,58.66,48.48,,46.928,percent of total billed charges,48.48% of total billed charges,58.66,48.48,,46.928,percent of total billed charges,48.48% of total billed charges,84.7,70,,67.76,percent of total billed charges,70% of total billed charges,84.7,70,,67.76,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,58.66,48.48,,46.928,percent of total billed charges,48.48% of total billed charges,108.9,90,,87.12,percent of total billed charges,90% of total billed charges,48.48,108.9,
IRBESARTAN CAP 150 MG,,,259,RC,J8499,HCPCS,outpatient,1,UN,13,7.80,,7.8,60,,6.24,percent of total billed charges,60% of total billed charges,6.24,48,,4.992,percent of total billed charges,48% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,9.1,70,,7.28,percent of total billed charges,70% of total billed charges,6.3,48.48,,5.04,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,6.3,48.48,,5.04,percent of total billed charges,48.48% of total billed charges,9.1,70,,7.28,percent of total billed charges,70% of total billed charges,9.1,70,,7.28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,6.3,48.48,,5.04,percent of total billed charges,48.48% of total billed charges,11.7,90,,9.36,percent of total billed charges,90% of total billed charges,6.3,90,
NOC^ PERINDOPRIL TAB [4 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,10,6.00,,6,60,,4.8,percent of total billed charges,60% of total billed charges,4.8,48,,3.84,percent of total billed charges,48% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,7,70,,5.6,percent of total billed charges,70% of total billed charges,4.85,48.48,,3.88,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,4.85,48.48,,3.88,percent of total billed charges,48.48% of total billed charges,7,70,,5.6,percent of total billed charges,70% of total billed charges,7,70,,5.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,4.85,48.48,,3.88,percent of total billed charges,48.48% of total billed charges,9,90,,7.2,percent of total billed charges,90% of total billed charges,4.85,90,
OXYMETAZOLINE 0.05% SPR,,,259,RC,J3490,HCPCS,outpatient,1,UN,21,12.60,,12.6,60,,10.08,percent of total billed charges,60% of total billed charges,10.08,48,,8.064,percent of total billed charges,48% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,14.7,70,,11.76,percent of total billed charges,70% of total billed charges,10.18,48.48,,8.144,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,10.18,48.48,,8.144,percent of total billed charges,48.48% of total billed charges,14.7,70,,11.76,percent of total billed charges,70% of total billed charges,14.7,70,,11.76,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,10.18,48.48,,8.144,percent of total billed charges,48.48% of total billed charges,18.9,90,,15.12,percent of total billed charges,90% of total billed charges,10.18,90,
NOC^ ARIPIPRAZOLE TAB [5 MG),,,259,RC,J3490,HCPCS,outpatient,1,UN,120,72.00,,72,60,,57.6,percent of total billed charges,60% of total billed charges,57.6,48,,46.08,percent of total billed charges,48% of total billed charges,60,50,,48,percent of total billed charges,50% of total billed charges,60,50,,48,percent of total billed charges,50% of total billed charges,60,50,,48,percent of total billed charges,50% of total billed charges,60,50,,48,percent of total billed charges,50% of total billed charges,84,70,,67.2,percent of total billed charges,70% of total billed charges,58.18,48.48,,46.544,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,58.18,48.48,,46.544,percent of total billed charges,48.48% of total billed charges,84,70,,67.2,percent of total billed charges,70% of total billed charges,84,70,,67.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,58.18,48.48,,46.544,percent of total billed charges,48.48% of total billed charges,108,90,,86.4,percent of total billed charges,90% of total billed charges,48.48,108,
AMIKACIN INJ [500 MG/2ML],,,636,RC,J0278,HCPCS,outpatient,5,UN,59,35.40,,35.4,60,,28.32,percent of total billed charges,60% of total billed charges,28.32,48,,22.656,percent of total billed charges,48% of total billed charges,1.43,100,,,fee schedule,100% of bcbs custom fee schedule,1.43,100,,,fee schedule,100% of bcbs custom fee schedule,1.59,111,,,fee schedule,111% of bcbs custom fee schedule,29.5,50,,23.6,percent of total billed charges,50% of total billed charges,41.3,70,,33.04,percent of total billed charges,70% of total billed charges,28.6,48.48,,22.88,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,28.6,48.48,,22.88,percent of total billed charges,48.48% of total billed charges,41.3,70,,33.04,percent of total billed charges,70% of total billed charges,41.3,70,,33.04,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,28.6,48.48,,22.88,percent of total billed charges,48.48% of total billed charges,53.1,90,,42.48,percent of total billed charges,90% of total billed charges,28.6,90,
AMINOPHYLLINE INJ 250MG,,,636,RC,J0280,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,9.92,100,,,fee schedule,100% of bcbs custom fee schedule,9.92,100,,,fee schedule,100% of bcbs custom fee schedule,11.01,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
AMIDATE AMP 10ML (2MG/ML),,,250,RC,J3490,HCPCS,outpatient,1,UN,32,19.20,,19.2,60,,15.36,percent of total billed charges,60% of total billed charges,15.36,48,,12.288,percent of total billed charges,48% of total billed charges,16,50,,12.8,percent of total billed charges,50% of total billed charges,16,50,,12.8,percent of total billed charges,50% of total billed charges,16,50,,12.8,percent of total billed charges,50% of total billed charges,16,50,,12.8,percent of total billed charges,50% of total billed charges,22.4,70,,17.92,percent of total billed charges,70% of total billed charges,15.51,48.48,,12.408,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,15.51,48.48,,12.408,percent of total billed charges,48.48% of total billed charges,22.4,70,,17.92,percent of total billed charges,70% of total billed charges,22.4,70,,17.92,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,15.51,48.48,,12.408,percent of total billed charges,48.48% of total billed charges,28.8,90,,23.04,percent of total billed charges,90% of total billed charges,15.51,90,
NOC^ AMOXICIL/POT CLAV SUSP 40,,,259,RC,J8499,HCPCS,outpatient,1,UN,141,84.60,,84.6,60,,67.68,percent of total billed charges,60% of total billed charges,67.68,48,,54.144,percent of total billed charges,48% of total billed charges,70.5,50,,56.4,percent of total billed charges,50% of total billed charges,70.5,50,,56.4,percent of total billed charges,50% of total billed charges,70.5,50,,56.4,percent of total billed charges,50% of total billed charges,70.5,50,,56.4,percent of total billed charges,50% of total billed charges,98.7,70,,78.96,percent of total billed charges,70% of total billed charges,68.36,48.48,,54.688,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,68.36,48.48,,54.688,percent of total billed charges,48.48% of total billed charges,98.7,70,,78.96,percent of total billed charges,70% of total billed charges,98.7,70,,78.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,68.36,48.48,,54.688,percent of total billed charges,48.48% of total billed charges,126.9,90,,101.52,percent of total billed charges,90% of total billed charges,48.48,126.9,
NOC^ ARTHROTEC TAB 75 MG,,,259,RC,J8499,HCPCS,outpatient,1,UN,14,8.40,,8.4,60,,6.72,percent of total billed charges,60% of total billed charges,6.72,48,,5.376,percent of total billed charges,48% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,9.8,70,,7.84,percent of total billed charges,70% of total billed charges,6.79,48.48,,5.432,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,6.79,48.48,,5.432,percent of total billed charges,48.48% of total billed charges,9.8,70,,7.84,percent of total billed charges,70% of total billed charges,9.8,70,,7.84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,6.79,48.48,,5.432,percent of total billed charges,48.48% of total billed charges,12.6,90,,10.08,percent of total billed charges,90% of total billed charges,6.79,90,
NOC^ AMOXICILLIN SUS [400 MG/5,,,259,RC,J3490,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
CEFAZOLIN INJ [1GM],,,636,RC,J0690,HCPCS,outpatient,1,UN,26,15.60,,15.6,60,,12.48,percent of total billed charges,60% of total billed charges,12.48,48,,9.984,percent of total billed charges,48% of total billed charges,1.07,100,,,fee schedule,100% of bcbs custom fee schedule,1.07,100,,,fee schedule,100% of bcbs custom fee schedule,1.19,111,,,fee schedule,111% of bcbs custom fee schedule,13,50,,10.4,percent of total billed charges,50% of total billed charges,18.2,70,,14.56,percent of total billed charges,70% of total billed charges,12.6,48.48,,10.08,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,12.6,48.48,,10.08,percent of total billed charges,48.48% of total billed charges,18.2,70,,14.56,percent of total billed charges,70% of total billed charges,18.2,70,,14.56,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,12.6,48.48,,10.08,percent of total billed charges,48.48% of total billed charges,23.4,90,,18.72,percent of total billed charges,90% of total billed charges,12.6,90,
NOC^ LEFLUNOMIDE TAB 20 MG,,,250,RC,J8499,HCPCS,outpatient,1,UN,24,14.40,,14.4,60,,11.52,percent of total billed charges,60% of total billed charges,11.52,48,,9.216,percent of total billed charges,48% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,21.6,90,,17.28,percent of total billed charges,90% of total billed charges,11.64,90,
NOC^ HYDROCORTISONE SUPP [25 M,,,259,RC,J3490,HCPCS,outpatient,1,UN,91,54.60,,54.6,60,,43.68,percent of total billed charges,60% of total billed charges,43.68,48,,34.944,percent of total billed charges,48% of total billed charges,45.5,50,,36.4,percent of total billed charges,50% of total billed charges,45.5,50,,36.4,percent of total billed charges,50% of total billed charges,45.5,50,,36.4,percent of total billed charges,50% of total billed charges,45.5,50,,36.4,percent of total billed charges,50% of total billed charges,63.7,70,,50.96,percent of total billed charges,70% of total billed charges,44.12,48.48,,35.296,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,44.12,48.48,,35.296,percent of total billed charges,48.48% of total billed charges,63.7,70,,50.96,percent of total billed charges,70% of total billed charges,63.7,70,,50.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,44.12,48.48,,35.296,percent of total billed charges,48.48% of total billed charges,81.9,90,,65.52,percent of total billed charges,90% of total billed charges,44.12,90,
CROFAB (ANTIVENOM),,,636,RC,J0840,HCPCS,outpatient,1,UN,7675,4605.00,,4605,60,,3684,percent of total billed charges,60% of total billed charges,3684,48,,2947.2,percent of total billed charges,48% of total billed charges,3348.13,100,,,fee schedule,100% of bcbs custom fee schedule,3348.13,100,,,fee schedule,100% of bcbs custom fee schedule,3716.42,111,,,fee schedule,111% of bcbs custom fee schedule,3837.5,50,,3070,percent of total billed charges,50% of total billed charges,5372.5,70,,4298,percent of total billed charges,70% of total billed charges,3720.84,48.48,,2976.672,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,3720.84,48.48,,2976.672,percent of total billed charges,48.48% of total billed charges,5372.5,70,,4298,percent of total billed charges,70% of total billed charges,5372.5,70,,4298,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,3720.84,48.48,,2976.672,percent of total billed charges,48.48% of total billed charges,6907.5,90,,5526,percent of total billed charges,90% of total billed charges,48.48,6907.5,
HYDRALAZINE INJ [20 MG/ML,,,250,RC,J0360,HCPCS,outpatient,1,UN,63,37.80,,37.8,60,,30.24,percent of total billed charges,60% of total billed charges,30.24,48,,24.192,percent of total billed charges,48% of total billed charges,3.72,100,,,fee schedule,100% of bcbs custom fee schedule,3.72,100,,,fee schedule,100% of bcbs custom fee schedule,4.13,111,,,fee schedule,111% of bcbs custom fee schedule,31.5,50,,25.2,percent of total billed charges,50% of total billed charges,44.1,70,,35.28,percent of total billed charges,70% of total billed charges,30.54,48.48,,24.432,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,30.54,48.48,,24.432,percent of total billed charges,48.48% of total billed charges,44.1,70,,35.28,percent of total billed charges,70% of total billed charges,44.1,70,,35.28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,30.54,48.48,,24.432,percent of total billed charges,48.48% of total billed charges,56.7,90,,45.36,percent of total billed charges,90% of total billed charges,30.54,90,
PHYTONADIONE INJ [10 MG/M,,,250,RC,J3430,HCPCS,outpatient,1,UN,233,139.80,,139.8,60,,111.84,percent of total billed charges,60% of total billed charges,111.84,48,,89.472,percent of total billed charges,48% of total billed charges,4.19,100,,,fee schedule,100% of bcbs custom fee schedule,4.19,100,,,fee schedule,100% of bcbs custom fee schedule,4.65,111,,,fee schedule,111% of bcbs custom fee schedule,116.5,50,,93.2,percent of total billed charges,50% of total billed charges,163.1,70,,130.48,percent of total billed charges,70% of total billed charges,112.96,48.48,,90.368,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,112.96,48.48,,90.368,percent of total billed charges,48.48% of total billed charges,163.1,70,,130.48,percent of total billed charges,70% of total billed charges,163.1,70,,130.48,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,112.96,48.48,,90.368,percent of total billed charges,48.48% of total billed charges,209.7,90,,167.76,percent of total billed charges,90% of total billed charges,48.48,209.7,
NOC^ ROSIGLITAZONE TAB [4 MG],,,259,RC,J3490,HCPCS,outpatient,1,UN,19,11.40,,11.4,60,,9.12,percent of total billed charges,60% of total billed charges,9.12,48,,7.296,percent of total billed charges,48% of total billed charges,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,13.3,70,,10.64,percent of total billed charges,70% of total billed charges,9.21,48.48,,7.368,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.21,48.48,,7.368,percent of total billed charges,48.48% of total billed charges,13.3,70,,10.64,percent of total billed charges,70% of total billed charges,13.3,70,,10.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.21,48.48,,7.368,percent of total billed charges,48.48% of total billed charges,17.1,90,,13.68,percent of total billed charges,90% of total billed charges,9.21,90,
MOXIFLOXACIN/ NACL PREMIX,,,250,RC,J2280,HCPCS,outpatient,1,UN,175,105.00,,105,60,,84,percent of total billed charges,60% of total billed charges,84,48,,67.2,percent of total billed charges,48% of total billed charges,10.3,100,,,fee schedule,100% of bcbs custom fee schedule,10.3,100,,,fee schedule,100% of bcbs custom fee schedule,11.43,111,,,fee schedule,111% of bcbs custom fee schedule,87.5,50,,70,percent of total billed charges,50% of total billed charges,122.5,70,,98,percent of total billed charges,70% of total billed charges,84.84,48.48,,67.872,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,84.84,48.48,,67.872,percent of total billed charges,48.48% of total billed charges,122.5,70,,98,percent of total billed charges,70% of total billed charges,122.5,70,,98,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,84.84,48.48,,67.872,percent of total billed charges,48.48% of total billed charges,157.5,90,,126,percent of total billed charges,90% of total billed charges,48.48,157.5,
NOC^ DUTASTERIDE CAP [0.5 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,25,15.00,,15,60,,12,percent of total billed charges,60% of total billed charges,12,48,,9.6,percent of total billed charges,48% of total billed charges,12.5,50,,10,percent of total billed charges,50% of total billed charges,12.5,50,,10,percent of total billed charges,50% of total billed charges,12.5,50,,10,percent of total billed charges,50% of total billed charges,12.5,50,,10,percent of total billed charges,50% of total billed charges,17.5,70,,14,percent of total billed charges,70% of total billed charges,12.12,48.48,,9.696,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,12.12,48.48,,9.696,percent of total billed charges,48.48% of total billed charges,17.5,70,,14,percent of total billed charges,70% of total billed charges,17.5,70,,14,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,12.12,48.48,,9.696,percent of total billed charges,48.48% of total billed charges,22.5,90,,18,percent of total billed charges,90% of total billed charges,12.12,90,
CANDESARTAN TAB [8 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
ATROPINE INJ [0.4 MG/ML],,,636,RC,J0461,HCPCS,outpatient,1,UN,39,23.40,,23.4,60,,18.72,percent of total billed charges,60% of total billed charges,18.72,48,,14.976,percent of total billed charges,48% of total billed charges,0.1,100,,,fee schedule,100% of bcbs custom fee schedule,0.1,100,,,fee schedule,100% of bcbs custom fee schedule,0.11,111,,,fee schedule,111% of bcbs custom fee schedule,19.5,50,,15.6,percent of total billed charges,50% of total billed charges,27.3,70,,21.84,percent of total billed charges,70% of total billed charges,18.91,48.48,,15.128,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,18.91,48.48,,15.128,percent of total billed charges,48.48% of total billed charges,27.3,70,,21.84,percent of total billed charges,70% of total billed charges,27.3,70,,21.84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,18.91,48.48,,15.128,percent of total billed charges,48.48% of total billed charges,35.1,90,,28.08,percent of total billed charges,90% of total billed charges,18.91,90,
ATROPINE SULF SYRINGE 1 M,,,636,RC,J0461,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,0.1,100,,,fee schedule,100% of bcbs custom fee schedule,0.1,100,,,fee schedule,100% of bcbs custom fee schedule,0.11,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
NOC^ IPRATROPIUM MDI,,,259,RC,J3490,HCPCS,outpatient,1,UN,2054,1232.40,,1232.4,60,,985.92,percent of total billed charges,60% of total billed charges,985.92,48,,788.736,percent of total billed charges,48% of total billed charges,1027,50,,821.6,percent of total billed charges,50% of total billed charges,1027,50,,821.6,percent of total billed charges,50% of total billed charges,1027,50,,821.6,percent of total billed charges,50% of total billed charges,1027,50,,821.6,percent of total billed charges,50% of total billed charges,1437.8,70,,1150.24,percent of total billed charges,70% of total billed charges,995.78,48.48,,796.624,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,995.78,48.48,,796.624,percent of total billed charges,48.48% of total billed charges,1437.8,70,,1150.24,percent of total billed charges,70% of total billed charges,1437.8,70,,1150.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,995.78,48.48,,796.624,percent of total billed charges,48.48% of total billed charges,1848.6,90,,1478.88,percent of total billed charges,90% of total billed charges,48.48,1848.6,
AMOXI/ POT CLAV TAB 250 M,,,259,RC,J3490,HCPCS,outpatient,1,UN,24,14.40,,14.4,60,,11.52,percent of total billed charges,60% of total billed charges,11.52,48,,9.216,percent of total billed charges,48% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,21.6,90,,17.28,percent of total billed charges,90% of total billed charges,11.64,90,
AZTREONAM INJ [1 GM],,,636,RC,J3490,HCPCS,outpatient,1,UN,140,84.00,,84,60,,67.2,percent of total billed charges,60% of total billed charges,67.2,48,,53.76,percent of total billed charges,48% of total billed charges,70,50,,56,percent of total billed charges,50% of total billed charges,70,50,,56,percent of total billed charges,50% of total billed charges,70,50,,56,percent of total billed charges,50% of total billed charges,70,50,,56,percent of total billed charges,50% of total billed charges,98,70,,78.4,percent of total billed charges,70% of total billed charges,67.87,48.48,,54.296,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,67.87,48.48,,54.296,percent of total billed charges,48.48% of total billed charges,98,70,,78.4,percent of total billed charges,70% of total billed charges,98,70,,78.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,67.87,48.48,,54.296,percent of total billed charges,48.48% of total billed charges,126,90,,100.8,percent of total billed charges,90% of total billed charges,48.48,126,
AZTREONAM INJ [2 GM],,,636,RC,S0073,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,15.57,100,,,fee schedule,100% of bcbs custom fee schedule,15.57,100,,,fee schedule,100% of bcbs custom fee schedule,17.28,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
NOC^ DIPYRIDAMOLE/ ASA CAP [20,,,259,RC,J8499,HCPCS,outpatient,1,UN,34,20.40,,20.4,60,,16.32,percent of total billed charges,60% of total billed charges,16.32,48,,13.056,percent of total billed charges,48% of total billed charges,17,50,,13.6,percent of total billed charges,50% of total billed charges,17,50,,13.6,percent of total billed charges,50% of total billed charges,17,50,,13.6,percent of total billed charges,50% of total billed charges,17,50,,13.6,percent of total billed charges,50% of total billed charges,23.8,70,,19.04,percent of total billed charges,70% of total billed charges,16.48,48.48,,13.184,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,16.48,48.48,,13.184,percent of total billed charges,48.48% of total billed charges,23.8,70,,19.04,percent of total billed charges,70% of total billed charges,23.8,70,,19.04,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,16.48,48.48,,13.184,percent of total billed charges,48.48% of total billed charges,30.6,90,,24.48,percent of total billed charges,90% of total billed charges,16.48,90,
NOC^ BRINZOLAMIDE OPTH 10 ML,,,259,RC,J3490,HCPCS,outpatient,1,UN,539,323.40,,323.4,60,,258.72,percent of total billed charges,60% of total billed charges,258.72,48,,206.976,percent of total billed charges,48% of total billed charges,269.5,50,,215.6,percent of total billed charges,50% of total billed charges,269.5,50,,215.6,percent of total billed charges,50% of total billed charges,269.5,50,,215.6,percent of total billed charges,50% of total billed charges,269.5,50,,215.6,percent of total billed charges,50% of total billed charges,377.3,70,,301.84,percent of total billed charges,70% of total billed charges,261.31,48.48,,209.048,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,261.31,48.48,,209.048,percent of total billed charges,48.48% of total billed charges,377.3,70,,301.84,percent of total billed charges,70% of total billed charges,377.3,70,,301.84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,261.31,48.48,,209.048,percent of total billed charges,48.48% of total billed charges,485.1,90,,388.08,percent of total billed charges,90% of total billed charges,48.48,485.1,
NOC^ AMOXICILLIN SUS [200 MG/5,,,259,RC,J3490,HCPCS,outpatient,1,UN,19,11.40,,11.4,60,,9.12,percent of total billed charges,60% of total billed charges,9.12,48,,7.296,percent of total billed charges,48% of total billed charges,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,13.3,70,,10.64,percent of total billed charges,70% of total billed charges,9.21,48.48,,7.368,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.21,48.48,,7.368,percent of total billed charges,48.48% of total billed charges,13.3,70,,10.64,percent of total billed charges,70% of total billed charges,13.3,70,,10.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.21,48.48,,7.368,percent of total billed charges,48.48% of total billed charges,17.1,90,,13.68,percent of total billed charges,90% of total billed charges,9.21,90,
AMOXICIL/ POT CLAV TAB [5,,,259,RC,J3490,HCPCS,outpatient,1,UN,16,9.60,,9.6,60,,7.68,percent of total billed charges,60% of total billed charges,7.68,48,,6.144,percent of total billed charges,48% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,11.2,70,,8.96,percent of total billed charges,70% of total billed charges,7.76,48.48,,6.208,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,7.76,48.48,,6.208,percent of total billed charges,48.48% of total billed charges,11.2,70,,8.96,percent of total billed charges,70% of total billed charges,11.2,70,,8.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,7.76,48.48,,6.208,percent of total billed charges,48.48% of total billed charges,14.4,90,,11.52,percent of total billed charges,90% of total billed charges,7.76,90,
ACETAMIN SOL 650MG/20.3ML,,,257,RC,A9150,HCPCS,outpatient,1,UN,11,6.60,,6.6,60,,5.28,percent of total billed charges,60% of total billed charges,5.28,48,,4.224,percent of total billed charges,48% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,9.9,90,,7.92,percent of total billed charges,90% of total billed charges,5.33,90,
NOC^ LUBIPROSTONE TAB [24 MCG],,,259,RC,J8499,HCPCS,outpatient,1,UN,30,18.00,,18,60,,14.4,percent of total billed charges,60% of total billed charges,14.4,48,,11.52,percent of total billed charges,48% of total billed charges,15,50,,12,percent of total billed charges,50% of total billed charges,15,50,,12,percent of total billed charges,50% of total billed charges,15,50,,12,percent of total billed charges,50% of total billed charges,15,50,,12,percent of total billed charges,50% of total billed charges,21,70,,16.8,percent of total billed charges,70% of total billed charges,14.54,48.48,,11.632,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,14.54,48.48,,11.632,percent of total billed charges,48.48% of total billed charges,21,70,,16.8,percent of total billed charges,70% of total billed charges,21,70,,16.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,14.54,48.48,,11.632,percent of total billed charges,48.48% of total billed charges,27,90,,21.6,percent of total billed charges,90% of total billed charges,14.54,90,
VIT- B-12 INJ [1000 MCG/M,43601527,CDM,636,RC,J3420,HCPCS,outpatient,1,UN,35,21.00,,21,60,,16.8,percent of total billed charges,60% of total billed charges,16.8,48,,13.44,percent of total billed charges,48% of total billed charges,2.02,100,,,fee schedule,100% of bcbs custom fee schedule,2.02,100,,,fee schedule,100% of bcbs custom fee schedule,2.24,111,,,fee schedule,111% of bcbs custom fee schedule,17.5,50,,14,percent of total billed charges,50% of total billed charges,24.5,70,,19.6,percent of total billed charges,70% of total billed charges,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,24.5,70,,19.6,percent of total billed charges,70% of total billed charges,24.5,70,,19.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,31.5,90,,25.2,percent of total billed charges,90% of total billed charges,16.97,90,
NOC^ FLUTICAS/ SALMET MDI [100,,,250,RC,J3490,HCPCS,outpatient,1,UN,729,437.40,,437.4,60,,349.92,percent of total billed charges,60% of total billed charges,349.92,48,,279.936,percent of total billed charges,48% of total billed charges,364.5,50,,291.6,percent of total billed charges,50% of total billed charges,364.5,50,,291.6,percent of total billed charges,50% of total billed charges,364.5,50,,291.6,percent of total billed charges,50% of total billed charges,364.5,50,,291.6,percent of total billed charges,50% of total billed charges,510.3,70,,408.24,percent of total billed charges,70% of total billed charges,353.42,48.48,,282.736,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,353.42,48.48,,282.736,percent of total billed charges,48.48% of total billed charges,510.3,70,,408.24,percent of total billed charges,70% of total billed charges,510.3,70,,408.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,353.42,48.48,,282.736,percent of total billed charges,48.48% of total billed charges,656.1,90,,524.88,percent of total billed charges,90% of total billed charges,48.48,656.1,
NOC^ FLUTICAS/ SALMET MDI [250,,,250,RC,J3490,HCPCS,outpatient,1,UN,729,437.40,,437.4,60,,349.92,percent of total billed charges,60% of total billed charges,349.92,48,,279.936,percent of total billed charges,48% of total billed charges,364.5,50,,291.6,percent of total billed charges,50% of total billed charges,364.5,50,,291.6,percent of total billed charges,50% of total billed charges,364.5,50,,291.6,percent of total billed charges,50% of total billed charges,364.5,50,,291.6,percent of total billed charges,50% of total billed charges,510.3,70,,408.24,percent of total billed charges,70% of total billed charges,353.42,48.48,,282.736,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,353.42,48.48,,282.736,percent of total billed charges,48.48% of total billed charges,510.3,70,,408.24,percent of total billed charges,70% of total billed charges,510.3,70,,408.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,353.42,48.48,,282.736,percent of total billed charges,48.48% of total billed charges,656.1,90,,524.88,percent of total billed charges,90% of total billed charges,48.48,656.1,
NOC^ SOTALOL TAB [80 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,11,6.60,,6.6,60,,5.28,percent of total billed charges,60% of total billed charges,5.28,48,,4.224,percent of total billed charges,48% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,9.9,90,,7.92,percent of total billed charges,90% of total billed charges,5.33,90,
NOC^ OLMESARTAN TAB [20 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,26,15.60,,15.6,60,,12.48,percent of total billed charges,60% of total billed charges,12.48,48,,9.984,percent of total billed charges,48% of total billed charges,13,50,,10.4,percent of total billed charges,50% of total billed charges,13,50,,10.4,percent of total billed charges,50% of total billed charges,13,50,,10.4,percent of total billed charges,50% of total billed charges,13,50,,10.4,percent of total billed charges,50% of total billed charges,18.2,70,,14.56,percent of total billed charges,70% of total billed charges,12.6,48.48,,10.08,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,12.6,48.48,,10.08,percent of total billed charges,48.48% of total billed charges,18.2,70,,14.56,percent of total billed charges,70% of total billed charges,18.2,70,,14.56,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,12.6,48.48,,10.08,percent of total billed charges,48.48% of total billed charges,23.4,90,,18.72,percent of total billed charges,90% of total billed charges,12.6,90,
NOC^ FLUTICAS/ SALMET MDI [500,,,250,RC,J3490,HCPCS,outpatient,1,UN,1188,712.80,,712.8,60,,570.24,percent of total billed charges,60% of total billed charges,570.24,48,,456.192,percent of total billed charges,48% of total billed charges,594,50,,475.2,percent of total billed charges,50% of total billed charges,594,50,,475.2,percent of total billed charges,50% of total billed charges,594,50,,475.2,percent of total billed charges,50% of total billed charges,594,50,,475.2,percent of total billed charges,50% of total billed charges,831.6,70,,665.28,percent of total billed charges,70% of total billed charges,575.94,48.48,,460.752,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,575.94,48.48,,460.752,percent of total billed charges,48.48% of total billed charges,831.6,70,,665.28,percent of total billed charges,70% of total billed charges,831.6,70,,665.28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,575.94,48.48,,460.752,percent of total billed charges,48.48% of total billed charges,1069.2,90,,855.36,percent of total billed charges,90% of total billed charges,48.48,1069.2,
NOC^ MUPIROCIN CRM 2%,,,259,RC,J3490,HCPCS,outpatient,1,UN,215,129.00,,129,60,,103.2,percent of total billed charges,60% of total billed charges,103.2,48,,82.56,percent of total billed charges,48% of total billed charges,107.5,50,,86,percent of total billed charges,50% of total billed charges,107.5,50,,86,percent of total billed charges,50% of total billed charges,107.5,50,,86,percent of total billed charges,50% of total billed charges,107.5,50,,86,percent of total billed charges,50% of total billed charges,150.5,70,,120.4,percent of total billed charges,70% of total billed charges,104.23,48.48,,83.384,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,104.23,48.48,,83.384,percent of total billed charges,48.48% of total billed charges,150.5,70,,120.4,percent of total billed charges,70% of total billed charges,150.5,70,,120.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,104.23,48.48,,83.384,percent of total billed charges,48.48% of total billed charges,193.5,90,,154.8,percent of total billed charges,90% of total billed charges,48.48,193.5,
NOC^ POVIDONE-IODINE 10% OIN,,,257,RC,J3490,HCPCS,outpatient,1,UN,26,15.60,,15.6,60,,12.48,percent of total billed charges,60% of total billed charges,12.48,48,,9.984,percent of total billed charges,48% of total billed charges,13,50,,10.4,percent of total billed charges,50% of total billed charges,13,50,,10.4,percent of total billed charges,50% of total billed charges,13,50,,10.4,percent of total billed charges,50% of total billed charges,13,50,,10.4,percent of total billed charges,50% of total billed charges,18.2,70,,14.56,percent of total billed charges,70% of total billed charges,12.6,48.48,,10.08,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,12.6,48.48,,10.08,percent of total billed charges,48.48% of total billed charges,18.2,70,,14.56,percent of total billed charges,70% of total billed charges,18.2,70,,14.56,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,12.6,48.48,,10.08,percent of total billed charges,48.48% of total billed charges,23.4,90,,18.72,percent of total billed charges,90% of total billed charges,12.6,90,
NOC^ FEXOFENADINE TAB [180 MG],,,259,RC,J3490,HCPCS,outpatient,1,UN,10,6.00,,6,60,,4.8,percent of total billed charges,60% of total billed charges,4.8,48,,3.84,percent of total billed charges,48% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,7,70,,5.6,percent of total billed charges,70% of total billed charges,4.85,48.48,,3.88,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,4.85,48.48,,3.88,percent of total billed charges,48.48% of total billed charges,7,70,,5.6,percent of total billed charges,70% of total billed charges,7,70,,5.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,4.85,48.48,,3.88,percent of total billed charges,48.48% of total billed charges,9,90,,7.2,percent of total billed charges,90% of total billed charges,4.85,90,
PENICILLIN G BENZ INJ [60,,,636,RC,J0561,HCPCS,outpatient,6,UN,699,419.40,,419.4,60,,335.52,percent of total billed charges,60% of total billed charges,335.52,48,,268.416,percent of total billed charges,48% of total billed charges,16.68,100,,,fee schedule,100% of bcbs custom fee schedule,16.68,100,,,fee schedule,100% of bcbs custom fee schedule,18.51,111,,,fee schedule,111% of bcbs custom fee schedule,349.5,50,,279.6,percent of total billed charges,50% of total billed charges,489.3,70,,391.44,percent of total billed charges,70% of total billed charges,338.88,48.48,,271.104,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,338.88,48.48,,271.104,percent of total billed charges,48.48% of total billed charges,489.3,70,,391.44,percent of total billed charges,70% of total billed charges,489.3,70,,391.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,338.88,48.48,,271.104,percent of total billed charges,48.48% of total billed charges,629.1,90,,503.28,percent of total billed charges,90% of total billed charges,48.48,629.1,
PENICILLIN G BNZ INJ 1.2M,,,636,RC,J0561,HCPCS,outpatient,12,UN,1209,725.40,,725.4,60,,580.32,percent of total billed charges,60% of total billed charges,580.32,48,,464.256,percent of total billed charges,48% of total billed charges,16.68,100,,,fee schedule,100% of bcbs custom fee schedule,16.68,100,,,fee schedule,100% of bcbs custom fee schedule,18.51,111,,,fee schedule,111% of bcbs custom fee schedule,604.5,50,,483.6,percent of total billed charges,50% of total billed charges,846.3,70,,677.04,percent of total billed charges,70% of total billed charges,586.12,48.48,,468.896,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,586.12,48.48,,468.896,percent of total billed charges,48.48% of total billed charges,846.3,70,,677.04,percent of total billed charges,70% of total billed charges,846.3,70,,677.04,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,586.12,48.48,,468.896,percent of total billed charges,48.48% of total billed charges,1088.1,90,,870.48,percent of total billed charges,90% of total billed charges,48.48,1088.1,
ISOSORBIDE/HYDRAL TAB 20/37.5,,,259,RC,J8499,HCPCS,outpatient,1,UN,19,11.40,,11.4,60,,9.12,percent of total billed charges,60% of total billed charges,9.12,48,,7.296,percent of total billed charges,48% of total billed charges,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,13.3,70,,10.64,percent of total billed charges,70% of total billed charges,9.21,48.48,,7.368,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.21,48.48,,7.368,percent of total billed charges,48.48% of total billed charges,13.3,70,,10.64,percent of total billed charges,70% of total billed charges,13.3,70,,10.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.21,48.48,,7.368,percent of total billed charges,48.48% of total billed charges,17.1,90,,13.68,percent of total billed charges,90% of total billed charges,9.21,90,
INS- GLULISINE INJ 100 UN,,,250,RC,J1815,HCPCS,outpatient,1,UN,24,14.40,,14.4,60,,11.52,percent of total billed charges,60% of total billed charges,11.52,48,,9.216,percent of total billed charges,48% of total billed charges,0.96,100,,,fee schedule,100% of bcbs custom fee schedule,0.96,100,,,fee schedule,100% of bcbs custom fee schedule,1.07,111,,,fee schedule,111% of bcbs custom fee schedule,12,50,,9.6,percent of total billed charges,50% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,21.6,90,,17.28,percent of total billed charges,90% of total billed charges,11.64,90,
NOC^ MOXIFLOXACIN TAB [400 MG],,,259,RC,J3490,HCPCS,outpatient,1,UN,92,55.20,,55.2,60,,44.16,percent of total billed charges,60% of total billed charges,44.16,48,,35.328,percent of total billed charges,48% of total billed charges,46,50,,36.8,percent of total billed charges,50% of total billed charges,46,50,,36.8,percent of total billed charges,50% of total billed charges,46,50,,36.8,percent of total billed charges,50% of total billed charges,46,50,,36.8,percent of total billed charges,50% of total billed charges,64.4,70,,51.52,percent of total billed charges,70% of total billed charges,44.6,48.48,,35.68,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,44.6,48.48,,35.68,percent of total billed charges,48.48% of total billed charges,64.4,70,,51.52,percent of total billed charges,70% of total billed charges,64.4,70,,51.52,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,44.6,48.48,,35.68,percent of total billed charges,48.48% of total billed charges,82.8,90,,66.24,percent of total billed charges,90% of total billed charges,44.6,90,
NOC^ FLUTICASONE 0.05% CRM,,,259,RC,J3490,HCPCS,outpatient,1,UN,89,53.40,,53.4,60,,42.72,percent of total billed charges,60% of total billed charges,42.72,48,,34.176,percent of total billed charges,48% of total billed charges,44.5,50,,35.6,percent of total billed charges,50% of total billed charges,44.5,50,,35.6,percent of total billed charges,50% of total billed charges,44.5,50,,35.6,percent of total billed charges,50% of total billed charges,44.5,50,,35.6,percent of total billed charges,50% of total billed charges,62.3,70,,49.84,percent of total billed charges,70% of total billed charges,43.15,48.48,,34.52,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,43.15,48.48,,34.52,percent of total billed charges,48.48% of total billed charges,62.3,70,,49.84,percent of total billed charges,70% of total billed charges,62.3,70,,49.84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,43.15,48.48,,34.52,percent of total billed charges,48.48% of total billed charges,80.1,90,,64.08,percent of total billed charges,90% of total billed charges,43.15,90,
NOC^ BETAXOLOL 0.25% DRP,,,259,RC,J3490,HCPCS,outpatient,1,UN,502,301.20,,301.2,60,,240.96,percent of total billed charges,60% of total billed charges,240.96,48,,192.768,percent of total billed charges,48% of total billed charges,251,50,,200.8,percent of total billed charges,50% of total billed charges,251,50,,200.8,percent of total billed charges,50% of total billed charges,251,50,,200.8,percent of total billed charges,50% of total billed charges,251,50,,200.8,percent of total billed charges,50% of total billed charges,351.4,70,,281.12,percent of total billed charges,70% of total billed charges,243.37,48.48,,194.696,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,243.37,48.48,,194.696,percent of total billed charges,48.48% of total billed charges,351.4,70,,281.12,percent of total billed charges,70% of total billed charges,351.4,70,,281.12,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,243.37,48.48,,194.696,percent of total billed charges,48.48% of total billed charges,451.8,90,,361.44,percent of total billed charges,90% of total billed charges,48.48,451.8,
DIPHENHYDRAMINE INJ [50 M,43601513,CDM,636,RC,J1200,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,0.72,100,,,fee schedule,100% of bcbs custom fee schedule,0.72,100,,,fee schedule,100% of bcbs custom fee schedule,0.8,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
ACTIGALL CAP 300MG,,,259,RC,,,outpatient,,,11,6.60,,6.6,60,,5.28,percent of total billed charges,60% of total billed charges,5.28,48,,4.224,percent of total billed charges,48% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,9.9,90,,7.92,percent of total billed charges,90% of total billed charges,5.33,90,
NOC^ RISEDRONATE TAB [35 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,410,246.00,,246,60,,196.8,percent of total billed charges,60% of total billed charges,196.8,48,,157.44,percent of total billed charges,48% of total billed charges,205,50,,164,percent of total billed charges,50% of total billed charges,205,50,,164,percent of total billed charges,50% of total billed charges,205,50,,164,percent of total billed charges,50% of total billed charges,205,50,,164,percent of total billed charges,50% of total billed charges,287,70,,229.6,percent of total billed charges,70% of total billed charges,198.77,48.48,,159.016,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,198.77,48.48,,159.016,percent of total billed charges,48.48% of total billed charges,287,70,,229.6,percent of total billed charges,70% of total billed charges,287,70,,229.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,198.77,48.48,,159.016,percent of total billed charges,48.48% of total billed charges,369,90,,295.2,percent of total billed charges,90% of total billed charges,48.48,369,
WATER BACT 30 ML,,,250,RC,A4216,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,0.45,100,,,fee schedule,100% of bcbs custom fee schedule,0.45,100,,,fee schedule,100% of bcbs custom fee schedule,0.5,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
NOC^ CALCIUM CL 10% INJ [10 ML,,,250,RC,J3490,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
CALCIUM GLUC 1GM/10ML,,,636,RC,J0612,HCPCS,outpatient,1,UN,49,29.40,,29.4,60,,23.52,percent of total billed charges,60% of total billed charges,23.52,48,,18.816,percent of total billed charges,48% of total billed charges,24.5,50,,19.6,percent of total billed charges,50% of total billed charges,24.5,50,,19.6,percent of total billed charges,50% of total billed charges,24.5,50,,19.6,percent of total billed charges,50% of total billed charges,24.5,50,,19.6,percent of total billed charges,50% of total billed charges,34.3,70,,27.44,percent of total billed charges,70% of total billed charges,23.76,48.48,,19.008,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,23.76,48.48,,19.008,percent of total billed charges,48.48% of total billed charges,34.3,70,,27.44,percent of total billed charges,70% of total billed charges,34.3,70,,27.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,23.76,48.48,,19.008,percent of total billed charges,48.48% of total billed charges,44.1,90,,35.28,percent of total billed charges,90% of total billed charges,23.76,90,
CALCIUM GLUC 2GM IVPB,,,636,RC,J0612,HCPCS,outpatient,,,88,52.80,,52.8,60,,42.24,percent of total billed charges,60% of total billed charges,42.24,48,,33.792,percent of total billed charges,48% of total billed charges,44,50,,35.2,percent of total billed charges,50% of total billed charges,44,50,,35.2,percent of total billed charges,50% of total billed charges,44,50,,35.2,percent of total billed charges,50% of total billed charges,44,50,,35.2,percent of total billed charges,50% of total billed charges,61.6,70,,49.28,percent of total billed charges,70% of total billed charges,42.66,48.48,,34.128,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,42.66,48.48,,34.128,percent of total billed charges,48.48% of total billed charges,61.6,70,,49.28,percent of total billed charges,70% of total billed charges,61.6,70,,49.28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,42.66,48.48,,34.128,percent of total billed charges,48.48% of total billed charges,79.2,90,,63.36,percent of total billed charges,90% of total billed charges,42.66,90,
NOC^ CIPROFLOXACIN 0.3% DRP,,,259,RC,J3490,HCPCS,outpatient,1,UN,51,30.60,,30.6,60,,24.48,percent of total billed charges,60% of total billed charges,24.48,48,,19.584,percent of total billed charges,48% of total billed charges,25.5,50,,20.4,percent of total billed charges,50% of total billed charges,25.5,50,,20.4,percent of total billed charges,50% of total billed charges,25.5,50,,20.4,percent of total billed charges,50% of total billed charges,25.5,50,,20.4,percent of total billed charges,50% of total billed charges,35.7,70,,28.56,percent of total billed charges,70% of total billed charges,24.72,48.48,,19.776,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,24.72,48.48,,19.776,percent of total billed charges,48.48% of total billed charges,35.7,70,,28.56,percent of total billed charges,70% of total billed charges,35.7,70,,28.56,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,24.72,48.48,,19.776,percent of total billed charges,48.48% of total billed charges,45.9,90,,36.72,percent of total billed charges,90% of total billed charges,24.72,90,
NOC^ SKIN CLEANSER/ EMOLLIENT,,,257,RC,J3490,HCPCS,outpatient,1,UN,41,24.60,,24.6,60,,19.68,percent of total billed charges,60% of total billed charges,19.68,48,,15.744,percent of total billed charges,48% of total billed charges,20.5,50,,16.4,percent of total billed charges,50% of total billed charges,20.5,50,,16.4,percent of total billed charges,50% of total billed charges,20.5,50,,16.4,percent of total billed charges,50% of total billed charges,20.5,50,,16.4,percent of total billed charges,50% of total billed charges,28.7,70,,22.96,percent of total billed charges,70% of total billed charges,19.88,48.48,,15.904,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,19.88,48.48,,15.904,percent of total billed charges,48.48% of total billed charges,28.7,70,,22.96,percent of total billed charges,70% of total billed charges,28.7,70,,22.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,19.88,48.48,,15.904,percent of total billed charges,48.48% of total billed charges,36.9,90,,29.52,percent of total billed charges,90% of total billed charges,19.88,90,
NOC^ CEFPROZIL SUS [250 MG/5ML,,,259,RC,J3490,HCPCS,outpatient,1,UN,157,94.20,,94.2,60,,75.36,percent of total billed charges,60% of total billed charges,75.36,48,,60.288,percent of total billed charges,48% of total billed charges,78.5,50,,62.8,percent of total billed charges,50% of total billed charges,78.5,50,,62.8,percent of total billed charges,50% of total billed charges,78.5,50,,62.8,percent of total billed charges,50% of total billed charges,78.5,50,,62.8,percent of total billed charges,50% of total billed charges,109.9,70,,87.92,percent of total billed charges,70% of total billed charges,76.11,48.48,,60.888,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,76.11,48.48,,60.888,percent of total billed charges,48.48% of total billed charges,109.9,70,,87.92,percent of total billed charges,70% of total billed charges,109.9,70,,87.92,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,76.11,48.48,,60.888,percent of total billed charges,48.48% of total billed charges,141.3,90,,113.04,percent of total billed charges,90% of total billed charges,48.48,141.3,
BICALUTAMIDE TAB [50 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,74,44.40,,44.4,60,,35.52,percent of total billed charges,60% of total billed charges,35.52,48,,28.416,percent of total billed charges,48% of total billed charges,37,50,,29.6,percent of total billed charges,50% of total billed charges,37,50,,29.6,percent of total billed charges,50% of total billed charges,37,50,,29.6,percent of total billed charges,50% of total billed charges,37,50,,29.6,percent of total billed charges,50% of total billed charges,51.8,70,,41.44,percent of total billed charges,70% of total billed charges,35.88,48.48,,28.704,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,35.88,48.48,,28.704,percent of total billed charges,48.48% of total billed charges,51.8,70,,41.44,percent of total billed charges,70% of total billed charges,51.8,70,,41.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,35.88,48.48,,28.704,percent of total billed charges,48.48% of total billed charges,66.6,90,,53.28,percent of total billed charges,90% of total billed charges,35.88,90,
NOC^ CEFUROXIME TAB [250 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,17,10.20,,10.2,60,,8.16,percent of total billed charges,60% of total billed charges,8.16,48,,6.528,percent of total billed charges,48% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,11.9,70,,9.52,percent of total billed charges,70% of total billed charges,8.24,48.48,,6.592,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,8.24,48.48,,6.592,percent of total billed charges,48.48% of total billed charges,11.9,70,,9.52,percent of total billed charges,70% of total billed charges,11.9,70,,9.52,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,8.24,48.48,,6.592,percent of total billed charges,48.48% of total billed charges,15.3,90,,12.24,percent of total billed charges,90% of total billed charges,8.24,90,
NOC^ CEFUROXIME TAB [500 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,45,27.00,,27,60,,21.6,percent of total billed charges,60% of total billed charges,21.6,48,,17.28,percent of total billed charges,48% of total billed charges,22.5,50,,18,percent of total billed charges,50% of total billed charges,22.5,50,,18,percent of total billed charges,50% of total billed charges,22.5,50,,18,percent of total billed charges,50% of total billed charges,22.5,50,,18,percent of total billed charges,50% of total billed charges,31.5,70,,25.2,percent of total billed charges,70% of total billed charges,21.82,48.48,,17.456,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,21.82,48.48,,17.456,percent of total billed charges,48.48% of total billed charges,31.5,70,,25.2,percent of total billed charges,70% of total billed charges,31.5,70,,25.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,21.82,48.48,,17.456,percent of total billed charges,48.48% of total billed charges,40.5,90,,32.4,percent of total billed charges,90% of total billed charges,21.82,90,
BETAMETHASONE INJ 3MG/0.5,43601688,CDM,636,RC,J0702,HCPCS,outpatient,1,UN,50,30.00,,30,60,,24,percent of total billed charges,60% of total billed charges,24,48,,19.2,percent of total billed charges,48% of total billed charges,7.21,100,,,fee schedule,100% of bcbs custom fee schedule,7.21,100,,,fee schedule,100% of bcbs custom fee schedule,8,111,,,fee schedule,111% of bcbs custom fee schedule,25,50,,20,percent of total billed charges,50% of total billed charges,35,70,,28,percent of total billed charges,70% of total billed charges,24.24,48.48,,19.392,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,24.24,48.48,,19.392,percent of total billed charges,48.48% of total billed charges,35,70,,28,percent of total billed charges,70% of total billed charges,35,70,,28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,24.24,48.48,,19.392,percent of total billed charges,48.48% of total billed charges,45,90,,36,percent of total billed charges,90% of total billed charges,24.24,90,
AMIODARONE INJ [50 MG/ML],,,636,RC,J0282,HCPCS,outpatient,1,UN,69,41.40,,41.4,60,,33.12,percent of total billed charges,60% of total billed charges,33.12,48,,26.496,percent of total billed charges,48% of total billed charges,0.54,100,,,fee schedule,100% of bcbs custom fee schedule,0.54,100,,,fee schedule,100% of bcbs custom fee schedule,0.6,111,,,fee schedule,111% of bcbs custom fee schedule,34.5,50,,27.6,percent of total billed charges,50% of total billed charges,48.3,70,,38.64,percent of total billed charges,70% of total billed charges,33.45,48.48,,26.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,33.45,48.48,,26.76,percent of total billed charges,48.48% of total billed charges,48.3,70,,38.64,percent of total billed charges,70% of total billed charges,48.3,70,,38.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,33.45,48.48,,26.76,percent of total billed charges,48.48% of total billed charges,62.1,90,,49.68,percent of total billed charges,90% of total billed charges,33.45,90,
NOC^ PHENOL SPR BTL,,,257,RC,J3490,HCPCS,outpatient,1,UN,21,12.60,,12.6,60,,10.08,percent of total billed charges,60% of total billed charges,10.08,48,,8.064,percent of total billed charges,48% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,14.7,70,,11.76,percent of total billed charges,70% of total billed charges,10.18,48.48,,8.144,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,10.18,48.48,,8.144,percent of total billed charges,48.48% of total billed charges,14.7,70,,11.76,percent of total billed charges,70% of total billed charges,14.7,70,,11.76,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,10.18,48.48,,8.144,percent of total billed charges,48.48% of total billed charges,18.9,90,,15.12,percent of total billed charges,90% of total billed charges,10.18,90,
NOC^ CIPROFLOXACIN/ HC DRP,,,259,RC,J3490,HCPCS,outpatient,1,UN,758,454.80,,454.8,60,,363.84,percent of total billed charges,60% of total billed charges,363.84,48,,291.072,percent of total billed charges,48% of total billed charges,379,50,,303.2,percent of total billed charges,50% of total billed charges,379,50,,303.2,percent of total billed charges,50% of total billed charges,379,50,,303.2,percent of total billed charges,50% of total billed charges,379,50,,303.2,percent of total billed charges,50% of total billed charges,530.6,70,,424.48,percent of total billed charges,70% of total billed charges,367.48,48.48,,293.984,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,367.48,48.48,,293.984,percent of total billed charges,48.48% of total billed charges,530.6,70,,424.48,percent of total billed charges,70% of total billed charges,530.6,70,,424.48,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,367.48,48.48,,293.984,percent of total billed charges,48.48% of total billed charges,682.2,90,,545.76,percent of total billed charges,90% of total billed charges,48.48,682.2,
NOC^ CIPROFLOXACIN TAB 250 MG,,,259,RC,J3490,HCPCS,outpatient,1,UN,18,10.80,,10.8,60,,8.64,percent of total billed charges,60% of total billed charges,8.64,48,,6.912,percent of total billed charges,48% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,12.6,70,,10.08,percent of total billed charges,70% of total billed charges,8.73,48.48,,6.984,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,8.73,48.48,,6.984,percent of total billed charges,48.48% of total billed charges,12.6,70,,10.08,percent of total billed charges,70% of total billed charges,12.6,70,,10.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,8.73,48.48,,6.984,percent of total billed charges,48.48% of total billed charges,16.2,90,,12.96,percent of total billed charges,90% of total billed charges,8.73,90,
NOC^ CIPROFLOXACIN TAB [500 MG,,,259,RC,J8499,HCPCS,outpatient,1,UN,26,15.60,,15.6,60,,12.48,percent of total billed charges,60% of total billed charges,12.48,48,,9.984,percent of total billed charges,48% of total billed charges,13,50,,10.4,percent of total billed charges,50% of total billed charges,13,50,,10.4,percent of total billed charges,50% of total billed charges,13,50,,10.4,percent of total billed charges,50% of total billed charges,13,50,,10.4,percent of total billed charges,50% of total billed charges,18.2,70,,14.56,percent of total billed charges,70% of total billed charges,12.6,48.48,,10.08,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,12.6,48.48,,10.08,percent of total billed charges,48.48% of total billed charges,18.2,70,,14.56,percent of total billed charges,70% of total billed charges,18.2,70,,14.56,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,12.6,48.48,,10.08,percent of total billed charges,48.48% of total billed charges,23.4,90,,18.72,percent of total billed charges,90% of total billed charges,12.6,90,
NOC^ CLINDAMYCIN CAP [150 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,15,9.00,,9,60,,7.2,percent of total billed charges,60% of total billed charges,7.2,48,,5.76,percent of total billed charges,48% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,13.5,90,,10.8,percent of total billed charges,90% of total billed charges,7.27,90,
NOC^ BRIMONIDINE 0.15% DRP,,,259,RC,J3490,HCPCS,outpatient,1,UN,283,169.80,,169.8,60,,135.84,percent of total billed charges,60% of total billed charges,135.84,48,,108.672,percent of total billed charges,48% of total billed charges,141.5,50,,113.2,percent of total billed charges,50% of total billed charges,141.5,50,,113.2,percent of total billed charges,50% of total billed charges,141.5,50,,113.2,percent of total billed charges,50% of total billed charges,141.5,50,,113.2,percent of total billed charges,50% of total billed charges,198.1,70,,158.48,percent of total billed charges,70% of total billed charges,137.2,48.48,,109.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,137.2,48.48,,109.76,percent of total billed charges,48.48% of total billed charges,198.1,70,,158.48,percent of total billed charges,70% of total billed charges,198.1,70,,158.48,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,137.2,48.48,,109.76,percent of total billed charges,48.48% of total billed charges,254.7,90,,203.76,percent of total billed charges,90% of total billed charges,48.48,254.7,
PROCHLORPERAZINE INJ [5 M,,,250,RC,J0780,HCPCS,outpatient,1,UN,89,53.40,,53.4,60,,42.72,percent of total billed charges,60% of total billed charges,42.72,48,,34.176,percent of total billed charges,48% of total billed charges,5.61,100,,,fee schedule,100% of bcbs custom fee schedule,5.61,100,,,fee schedule,100% of bcbs custom fee schedule,6.23,111,,,fee schedule,111% of bcbs custom fee schedule,44.5,50,,35.6,percent of total billed charges,50% of total billed charges,62.3,70,,49.84,percent of total billed charges,70% of total billed charges,43.15,48.48,,34.52,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,43.15,48.48,,34.52,percent of total billed charges,48.48% of total billed charges,62.3,70,,49.84,percent of total billed charges,70% of total billed charges,62.3,70,,49.84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,43.15,48.48,,34.52,percent of total billed charges,48.48% of total billed charges,80.1,90,,64.08,percent of total billed charges,90% of total billed charges,43.15,90,
ALBUTEROL/ IPRATROPIUM MDI,,,250,RC,J3490,HCPCS,outpatient,1,UN,2129,1277.40,,1277.4,60,,1021.92,percent of total billed charges,60% of total billed charges,1021.92,48,,817.536,percent of total billed charges,48% of total billed charges,1064.5,50,,851.6,percent of total billed charges,50% of total billed charges,1064.5,50,,851.6,percent of total billed charges,50% of total billed charges,1064.5,50,,851.6,percent of total billed charges,50% of total billed charges,1064.5,50,,851.6,percent of total billed charges,50% of total billed charges,1490.3,70,,1192.24,percent of total billed charges,70% of total billed charges,1032.14,48.48,,825.712,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,1032.14,48.48,,825.712,percent of total billed charges,48.48% of total billed charges,1490.3,70,,1192.24,percent of total billed charges,70% of total billed charges,1490.3,70,,1192.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,1032.14,48.48,,825.712,percent of total billed charges,48.48% of total billed charges,1916.1,90,,1532.88,percent of total billed charges,90% of total billed charges,48.48,1916.1,
NOC^ NADOLOL TAB [20 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,25,15.00,,15,60,,12,percent of total billed charges,60% of total billed charges,12,48,,9.6,percent of total billed charges,48% of total billed charges,12.5,50,,10,percent of total billed charges,50% of total billed charges,12.5,50,,10,percent of total billed charges,50% of total billed charges,12.5,50,,10,percent of total billed charges,50% of total billed charges,12.5,50,,10,percent of total billed charges,50% of total billed charges,17.5,70,,14,percent of total billed charges,70% of total billed charges,12.12,48.48,,9.696,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,12.12,48.48,,9.696,percent of total billed charges,48.48% of total billed charges,17.5,70,,14,percent of total billed charges,70% of total billed charges,17.5,70,,14,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,12.12,48.48,,9.696,percent of total billed charges,48.48% of total billed charges,22.5,90,,18,percent of total billed charges,90% of total billed charges,12.12,90,
NOC^ NEO/POLY/ HC DRP [EYE],,,259,RC,J3490,HCPCS,outpatient,1,UN,682,409.20,,409.2,60,,327.36,percent of total billed charges,60% of total billed charges,327.36,48,,261.888,percent of total billed charges,48% of total billed charges,341,50,,272.8,percent of total billed charges,50% of total billed charges,341,50,,272.8,percent of total billed charges,50% of total billed charges,341,50,,272.8,percent of total billed charges,50% of total billed charges,341,50,,272.8,percent of total billed charges,50% of total billed charges,477.4,70,,381.92,percent of total billed charges,70% of total billed charges,330.63,48.48,,264.504,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,330.63,48.48,,264.504,percent of total billed charges,48.48% of total billed charges,477.4,70,,381.92,percent of total billed charges,70% of total billed charges,477.4,70,,381.92,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,330.63,48.48,,264.504,percent of total billed charges,48.48% of total billed charges,613.8,90,,491.04,percent of total billed charges,90% of total billed charges,48.48,613.8,
NOC^ NEO/POLY/HC DRP SOL [EAR],,,259,RC,J3490,HCPCS,outpatient,1,UN,210,126.00,,126,60,,100.8,percent of total billed charges,60% of total billed charges,100.8,48,,80.64,percent of total billed charges,48% of total billed charges,105,50,,84,percent of total billed charges,50% of total billed charges,105,50,,84,percent of total billed charges,50% of total billed charges,105,50,,84,percent of total billed charges,50% of total billed charges,105,50,,84,percent of total billed charges,50% of total billed charges,147,70,,117.6,percent of total billed charges,70% of total billed charges,101.81,48.48,,81.448,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,101.81,48.48,,81.448,percent of total billed charges,48.48% of total billed charges,147,70,,117.6,percent of total billed charges,70% of total billed charges,147,70,,117.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,101.81,48.48,,81.448,percent of total billed charges,48.48% of total billed charges,189,90,,151.2,percent of total billed charges,90% of total billed charges,48.48,189,
CLONIDINE PAT 0.1 MG/24H,,,250,RC,J3490,HCPCS,outpatient,1,UN,133,79.80,,79.8,60,,63.84,percent of total billed charges,60% of total billed charges,63.84,48,,51.072,percent of total billed charges,48% of total billed charges,66.5,50,,53.2,percent of total billed charges,50% of total billed charges,66.5,50,,53.2,percent of total billed charges,50% of total billed charges,66.5,50,,53.2,percent of total billed charges,50% of total billed charges,66.5,50,,53.2,percent of total billed charges,50% of total billed charges,93.1,70,,74.48,percent of total billed charges,70% of total billed charges,64.48,48.48,,51.584,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,64.48,48.48,,51.584,percent of total billed charges,48.48% of total billed charges,93.1,70,,74.48,percent of total billed charges,70% of total billed charges,93.1,70,,74.48,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,64.48,48.48,,51.584,percent of total billed charges,48.48% of total billed charges,119.7,90,,95.76,percent of total billed charges,90% of total billed charges,48.48,119.7,
NOC^ CLEOCIN PREMX [900MG/50ML,,,636,RC,J0736,HCPCS,outpatient,3,UN,73.05,43.83,,43.83,60,,35.064,percent of total billed charges,60% of total billed charges,35.06,48,,28.048,percent of total billed charges,48% of total billed charges,36.53,50,,29.224,percent of total billed charges,50% of total billed charges,36.53,50,,29.224,percent of total billed charges,50% of total billed charges,36.53,50,,29.224,percent of total billed charges,50% of total billed charges,36.53,50,,29.224,percent of total billed charges,50% of total billed charges,51.14,70,,40.912,percent of total billed charges,70% of total billed charges,35.41,48.48,,28.328,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,35.41,48.48,,28.328,percent of total billed charges,48.48% of total billed charges,51.14,70,,40.912,percent of total billed charges,70% of total billed charges,51.14,70,,40.912,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,35.41,48.48,,28.328,percent of total billed charges,48.48% of total billed charges,65.75,90,,52.6,percent of total billed charges,90% of total billed charges,35.41,90,
NOC^ COLCHICINE TAB [0.6 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,45,27.00,,27,60,,21.6,percent of total billed charges,60% of total billed charges,21.6,48,,17.28,percent of total billed charges,48% of total billed charges,22.5,50,,18,percent of total billed charges,50% of total billed charges,22.5,50,,18,percent of total billed charges,50% of total billed charges,22.5,50,,18,percent of total billed charges,50% of total billed charges,22.5,50,,18,percent of total billed charges,50% of total billed charges,31.5,70,,25.2,percent of total billed charges,70% of total billed charges,21.82,48.48,,17.456,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,21.82,48.48,,17.456,percent of total billed charges,48.48% of total billed charges,31.5,70,,25.2,percent of total billed charges,70% of total billed charges,31.5,70,,25.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,21.82,48.48,,17.456,percent of total billed charges,48.48% of total billed charges,40.5,90,,32.4,percent of total billed charges,90% of total billed charges,21.82,90,
CLINDAMYCIN INJ [600 MG/4,,,636,RC,J0736,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
CLOTRIMAZ/BETAMETH 15GM,,,259,RC,,,outpatient,,,119,71.40,,71.4,60,,57.12,percent of total billed charges,60% of total billed charges,57.12,48,,45.696,percent of total billed charges,48% of total billed charges,59.5,50,,47.6,percent of total billed charges,50% of total billed charges,59.5,50,,47.6,percent of total billed charges,50% of total billed charges,59.5,50,,47.6,percent of total billed charges,50% of total billed charges,59.5,50,,47.6,percent of total billed charges,50% of total billed charges,83.3,70,,66.64,percent of total billed charges,70% of total billed charges,57.69,48.48,,46.152,percent of total billed charges,48.48% of total billed charges,57.69,48.48,,46.152,percent of total billed charges,48.48% of total billed charges,57.69,48.48,,46.152,percent of total billed charges,48.48% of total billed charges,83.3,70,,66.64,percent of total billed charges,70% of total billed charges,83.3,70,,66.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,57.69,48.48,,46.152,percent of total billed charges,48.48% of total billed charges,107.1,90,,85.68,percent of total billed charges,90% of total billed charges,48.48,107.1,
NOC^ LEVOBUNOLOL  0.5%  DRP,,,259,RC,J3490,HCPCS,outpatient,1,UN,254,152.40,,152.4,60,,121.92,percent of total billed charges,60% of total billed charges,121.92,48,,97.536,percent of total billed charges,48% of total billed charges,127,50,,101.6,percent of total billed charges,50% of total billed charges,127,50,,101.6,percent of total billed charges,50% of total billed charges,127,50,,101.6,percent of total billed charges,50% of total billed charges,127,50,,101.6,percent of total billed charges,50% of total billed charges,177.8,70,,142.24,percent of total billed charges,70% of total billed charges,123.14,48.48,,98.512,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,123.14,48.48,,98.512,percent of total billed charges,48.48% of total billed charges,177.8,70,,142.24,percent of total billed charges,70% of total billed charges,177.8,70,,142.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,123.14,48.48,,98.512,percent of total billed charges,48.48% of total billed charges,228.6,90,,182.88,percent of total billed charges,90% of total billed charges,48.48,228.6,
CLONIDINE PAT 0.2MG/24HR,,,250,RC,J3490,HCPCS,outpatient,1,UN,224,134.40,,134.4,60,,107.52,percent of total billed charges,60% of total billed charges,107.52,48,,86.016,percent of total billed charges,48% of total billed charges,112,50,,89.6,percent of total billed charges,50% of total billed charges,112,50,,89.6,percent of total billed charges,50% of total billed charges,112,50,,89.6,percent of total billed charges,50% of total billed charges,112,50,,89.6,percent of total billed charges,50% of total billed charges,156.8,70,,125.44,percent of total billed charges,70% of total billed charges,108.6,48.48,,86.88,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,108.6,48.48,,86.88,percent of total billed charges,48.48% of total billed charges,156.8,70,,125.44,percent of total billed charges,70% of total billed charges,156.8,70,,125.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,108.6,48.48,,86.88,percent of total billed charges,48.48% of total billed charges,201.6,90,,161.28,percent of total billed charges,90% of total billed charges,48.48,201.6,
CLONIDINE PAT 0.3MG/24HR,,,250,RC,J3490,HCPCS,outpatient,1,UN,310,186.00,,186,60,,148.8,percent of total billed charges,60% of total billed charges,148.8,48,,119.04,percent of total billed charges,48% of total billed charges,155,50,,124,percent of total billed charges,50% of total billed charges,155,50,,124,percent of total billed charges,50% of total billed charges,155,50,,124,percent of total billed charges,50% of total billed charges,155,50,,124,percent of total billed charges,50% of total billed charges,217,70,,173.6,percent of total billed charges,70% of total billed charges,150.29,48.48,,120.232,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,150.29,48.48,,120.232,percent of total billed charges,48.48% of total billed charges,217,70,,173.6,percent of total billed charges,70% of total billed charges,217,70,,173.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,150.29,48.48,,120.232,percent of total billed charges,48.48% of total billed charges,279,90,,223.2,percent of total billed charges,90% of total billed charges,48.48,279,
NOC^ DIGOXIN ELX .05MG/ML 60 M,,,259,RC,J3490,HCPCS,outpatient,1,UN,672,403.20,,403.2,60,,322.56,percent of total billed charges,60% of total billed charges,322.56,48,,258.048,percent of total billed charges,48% of total billed charges,336,50,,268.8,percent of total billed charges,50% of total billed charges,336,50,,268.8,percent of total billed charges,50% of total billed charges,336,50,,268.8,percent of total billed charges,50% of total billed charges,336,50,,268.8,percent of total billed charges,50% of total billed charges,470.4,70,,376.32,percent of total billed charges,70% of total billed charges,325.79,48.48,,260.632,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,325.79,48.48,,260.632,percent of total billed charges,48.48% of total billed charges,470.4,70,,376.32,percent of total billed charges,70% of total billed charges,470.4,70,,376.32,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,325.79,48.48,,260.632,percent of total billed charges,48.48% of total billed charges,604.8,90,,483.84,percent of total billed charges,90% of total billed charges,48.48,604.8,
NOC^ VALSARTAN TAB [160 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,21,12.60,,12.6,60,,10.08,percent of total billed charges,60% of total billed charges,10.08,48,,8.064,percent of total billed charges,48% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,14.7,70,,11.76,percent of total billed charges,70% of total billed charges,10.18,48.48,,8.144,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,10.18,48.48,,8.144,percent of total billed charges,48.48% of total billed charges,14.7,70,,11.76,percent of total billed charges,70% of total billed charges,14.7,70,,11.76,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,10.18,48.48,,8.144,percent of total billed charges,48.48% of total billed charges,18.9,90,,15.12,percent of total billed charges,90% of total billed charges,10.18,90,
NOC^ VALSARTAN TAB  [80 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,19,11.40,,11.4,60,,9.12,percent of total billed charges,60% of total billed charges,9.12,48,,7.296,percent of total billed charges,48% of total billed charges,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,13.3,70,,10.64,percent of total billed charges,70% of total billed charges,9.21,48.48,,7.368,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.21,48.48,,7.368,percent of total billed charges,48.48% of total billed charges,13.3,70,,10.64,percent of total billed charges,70% of total billed charges,13.3,70,,10.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.21,48.48,,7.368,percent of total billed charges,48.48% of total billed charges,17.1,90,,13.68,percent of total billed charges,90% of total billed charges,9.21,90,
DEBROX 15cc,,,257,RC,,,outpatient,,,11,6.60,,6.6,60,,5.28,percent of total billed charges,60% of total billed charges,5.28,48,,4.224,percent of total billed charges,48% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,9.9,90,,7.92,percent of total billed charges,90% of total billed charges,5.33,90,
NOC^ VALSARTAN/ HCTZ TAB [80-1,,,259,RC,J3490,HCPCS,outpatient,1,UN,17,10.20,,10.2,60,,8.16,percent of total billed charges,60% of total billed charges,8.16,48,,6.528,percent of total billed charges,48% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,11.9,70,,9.52,percent of total billed charges,70% of total billed charges,8.24,48.48,,6.592,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,8.24,48.48,,6.592,percent of total billed charges,48.48% of total billed charges,11.9,70,,9.52,percent of total billed charges,70% of total billed charges,11.9,70,,9.52,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,8.24,48.48,,6.592,percent of total billed charges,48.48% of total billed charges,15.3,90,,12.24,percent of total billed charges,90% of total billed charges,8.24,90,
DEXAMETHASONE INJ [4 MG/M,,,636,RC,J7638,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,0.12,100,,,fee schedule,100% of bcbs custom fee schedule,0.12,100,,,fee schedule,100% of bcbs custom fee schedule,0.13,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
NOC^ TOLTERODINE TAB [2 MG],,,259,RC,J3490,HCPCS,outpatient,1,UN,18,10.80,,10.8,60,,8.64,percent of total billed charges,60% of total billed charges,8.64,48,,6.912,percent of total billed charges,48% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,12.6,70,,10.08,percent of total billed charges,70% of total billed charges,8.73,48.48,,6.984,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,8.73,48.48,,6.984,percent of total billed charges,48.48% of total billed charges,12.6,70,,10.08,percent of total billed charges,70% of total billed charges,12.6,70,,10.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,8.73,48.48,,6.984,percent of total billed charges,48.48% of total billed charges,16.2,90,,12.96,percent of total billed charges,90% of total billed charges,8.73,90,
NOC^ DIVALPR/ VALPROIC ACID TA,,,259,RC,J3490,HCPCS,outpatient,1,UN,12,7.20,,7.2,60,,5.76,percent of total billed charges,60% of total billed charges,5.76,48,,4.608,percent of total billed charges,48% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,8.4,70,,6.72,percent of total billed charges,70% of total billed charges,5.82,48.48,,4.656,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,5.82,48.48,,4.656,percent of total billed charges,48.48% of total billed charges,8.4,70,,6.72,percent of total billed charges,70% of total billed charges,8.4,70,,6.72,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,5.82,48.48,,4.656,percent of total billed charges,48.48% of total billed charges,10.8,90,,8.64,percent of total billed charges,90% of total billed charges,5.82,90,
NOC^ TOLTERODINE CAP [4 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,49,29.40,,29.4,60,,23.52,percent of total billed charges,60% of total billed charges,23.52,48,,18.816,percent of total billed charges,48% of total billed charges,24.5,50,,19.6,percent of total billed charges,50% of total billed charges,24.5,50,,19.6,percent of total billed charges,50% of total billed charges,24.5,50,,19.6,percent of total billed charges,50% of total billed charges,24.5,50,,19.6,percent of total billed charges,50% of total billed charges,34.3,70,,27.44,percent of total billed charges,70% of total billed charges,23.76,48.48,,19.008,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,23.76,48.48,,19.008,percent of total billed charges,48.48% of total billed charges,34.3,70,,27.44,percent of total billed charges,70% of total billed charges,34.3,70,,27.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,23.76,48.48,,19.008,percent of total billed charges,48.48% of total billed charges,44.1,90,,35.28,percent of total billed charges,90% of total billed charges,23.76,90,
MEPERIDINE INJ [25 MG/ML],,,636,RC,J2175,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,9.19,100,,,fee schedule,100% of bcbs custom fee schedule,9.19,100,,,fee schedule,100% of bcbs custom fee schedule,10.2,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
METHYLPREDNISOL INJ 80MG,43601506,CDM,636,RC,J1010,HCPCS,outpatient,80,UN,97.6,58.56,,58.56,60,,46.848,percent of total billed charges,60% of total billed charges,46.85,48,,37.48,percent of total billed charges,48% of total billed charges,48.8,50,,39.04,percent of total billed charges,50% of total billed charges,48.8,50,,39.04,percent of total billed charges,50% of total billed charges,48.8,50,,39.04,percent of total billed charges,50% of total billed charges,48.8,50,,39.04,percent of total billed charges,50% of total billed charges,68.32,70,,54.656,percent of total billed charges,70% of total billed charges,47.32,48.48,,37.856,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,47.32,48.48,,37.856,percent of total billed charges,48.48% of total billed charges,68.32,70,,54.656,percent of total billed charges,70% of total billed charges,68.32,70,,54.656,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,47.32,48.48,,37.856,percent of total billed charges,48.48% of total billed charges,87.84,90,,70.272,percent of total billed charges,90% of total billed charges,47.32,90,
TESTOSTERONE CYP 200 MG INJ,43601508,CDM,250,RC,J1071,HCPCS,outpatient,200,UN,102,61.20,,61.2,60,,48.96,percent of total billed charges,60% of total billed charges,48.96,48,,39.168,percent of total billed charges,48% of total billed charges,0.03,100,,,fee schedule,100% of bcbs custom fee schedule,0.03,100,,,fee schedule,100% of bcbs custom fee schedule,0.03,111,,,fee schedule,111% of bcbs custom fee schedule,51,50,,40.8,percent of total billed charges,50% of total billed charges,71.4,70,,57.12,percent of total billed charges,70% of total billed charges,49.45,48.48,,39.56,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,49.45,48.48,,39.56,percent of total billed charges,48.48% of total billed charges,71.4,70,,57.12,percent of total billed charges,70% of total billed charges,71.4,70,,57.12,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,49.45,48.48,,39.56,percent of total billed charges,48.48% of total billed charges,91.8,90,,73.44,percent of total billed charges,90% of total billed charges,48.48,91.8,
DESMOPRESSIN 1MCG INJ,,,636,RC,J2597,HCPCS,outpatient,1,UN,183,109.80,,109.8,60,,87.84,percent of total billed charges,60% of total billed charges,87.84,48,,70.272,percent of total billed charges,48% of total billed charges,11.5,100,,,fee schedule,100% of bcbs custom fee schedule,11.5,100,,,fee schedule,100% of bcbs custom fee schedule,12.77,111,,,fee schedule,111% of bcbs custom fee schedule,91.5,50,,73.2,percent of total billed charges,50% of total billed charges,128.1,70,,102.48,percent of total billed charges,70% of total billed charges,88.72,48.48,,70.976,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,88.72,48.48,,70.976,percent of total billed charges,48.48% of total billed charges,128.1,70,,102.48,percent of total billed charges,70% of total billed charges,128.1,70,,102.48,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,88.72,48.48,,70.976,percent of total billed charges,48.48% of total billed charges,164.7,90,,131.76,percent of total billed charges,90% of total billed charges,48.48,164.7,
NOC^ DEXTROSE 25% INJ SYR [10M,,,250,RC,J3490,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
NOC^ DEXTROSE 50% INJ SYR [50M,,,250,RC,J3490,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
NOC^ ACETAZOLAMIDE TAB 250 MG,,,259,RC,J3490,HCPCS,outpatient,1,UN,17,10.20,,10.2,60,,8.16,percent of total billed charges,60% of total billed charges,8.16,48,,6.528,percent of total billed charges,48% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,11.9,70,,9.52,percent of total billed charges,70% of total billed charges,8.24,48.48,,6.592,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,8.24,48.48,,6.592,percent of total billed charges,48.48% of total billed charges,11.9,70,,9.52,percent of total billed charges,70% of total billed charges,11.9,70,,9.52,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,8.24,48.48,,6.592,percent of total billed charges,48.48% of total billed charges,15.3,90,,12.24,percent of total billed charges,90% of total billed charges,8.24,90,
PHENYTOIN INJ 250 MG/5ML,,,250,RC,J1165,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,0.55,100,,,fee schedule,100% of bcbs custom fee schedule,0.55,100,,,fee schedule,100% of bcbs custom fee schedule,0.61,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
NOC^ PHENYTOIN SUS [100 MG/4ML,,,259,RC,J3490,HCPCS,outpatient,1,UN,35,21.00,,21,60,,16.8,percent of total billed charges,60% of total billed charges,16.8,48,,13.44,percent of total billed charges,48% of total billed charges,17.5,50,,14,percent of total billed charges,50% of total billed charges,17.5,50,,14,percent of total billed charges,50% of total billed charges,17.5,50,,14,percent of total billed charges,50% of total billed charges,17.5,50,,14,percent of total billed charges,50% of total billed charges,24.5,70,,19.6,percent of total billed charges,70% of total billed charges,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,24.5,70,,19.6,percent of total billed charges,70% of total billed charges,24.5,70,,19.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,31.5,90,,25.2,percent of total billed charges,90% of total billed charges,16.97,90,
AMPICILLIN INJ [1 GM],,,636,RC,J0290,HCPCS,outpatient,2,UN,33,19.80,,19.8,60,,15.84,percent of total billed charges,60% of total billed charges,15.84,48,,12.672,percent of total billed charges,48% of total billed charges,1.01,100,,,fee schedule,100% of bcbs custom fee schedule,1.01,100,,,fee schedule,100% of bcbs custom fee schedule,1.12,111,,,fee schedule,111% of bcbs custom fee schedule,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,23.1,70,,18.48,percent of total billed charges,70% of total billed charges,16,48.48,,12.8,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,16,48.48,,12.8,percent of total billed charges,48.48% of total billed charges,23.1,70,,18.48,percent of total billed charges,70% of total billed charges,23.1,70,,18.48,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,16,48.48,,12.8,percent of total billed charges,48.48% of total billed charges,29.7,90,,23.76,percent of total billed charges,90% of total billed charges,16,90,
DEXAMETHASONE OPT SOL 5ML,,,259,RC,J3490,HCPCS,outpatient,1,UN,258,154.80,,154.8,60,,123.84,percent of total billed charges,60% of total billed charges,123.84,48,,99.072,percent of total billed charges,48% of total billed charges,129,50,,103.2,percent of total billed charges,50% of total billed charges,129,50,,103.2,percent of total billed charges,50% of total billed charges,129,50,,103.2,percent of total billed charges,50% of total billed charges,129,50,,103.2,percent of total billed charges,50% of total billed charges,180.6,70,,144.48,percent of total billed charges,70% of total billed charges,125.08,48.48,,100.064,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,125.08,48.48,,100.064,percent of total billed charges,48.48% of total billed charges,180.6,70,,144.48,percent of total billed charges,70% of total billed charges,180.6,70,,144.48,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,125.08,48.48,,100.064,percent of total billed charges,48.48% of total billed charges,232.2,90,,185.76,percent of total billed charges,90% of total billed charges,48.48,232.2,
MEDRXYPROGESTER INJ 150MG,43601507,CDM,636,RC,J1050,HCPCS,outpatient,1,UN,392,235.20,,235.2,60,,188.16,percent of total billed charges,60% of total billed charges,188.16,48,,150.528,percent of total billed charges,48% of total billed charges,0.62,100,,,fee schedule,100% of bcbs custom fee schedule,0.62,100,,,fee schedule,100% of bcbs custom fee schedule,0.69,111,,,fee schedule,111% of bcbs custom fee schedule,196,50,,156.8,percent of total billed charges,50% of total billed charges,274.4,70,,219.52,percent of total billed charges,70% of total billed charges,190.04,48.48,,152.032,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,190.04,48.48,,152.032,percent of total billed charges,48.48% of total billed charges,274.4,70,,219.52,percent of total billed charges,70% of total billed charges,274.4,70,,219.52,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,190.04,48.48,,152.032,percent of total billed charges,48.48% of total billed charges,352.8,90,,282.24,percent of total billed charges,90% of total billed charges,48.48,352.8,
DOBUTAMINE INJ 250MG/250M,,,636,RC,J1250,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,6.26,100,,,fee schedule,100% of bcbs custom fee schedule,6.26,100,,,fee schedule,100% of bcbs custom fee schedule,6.95,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
NOC^ OXYBUTYNIN XL TAB [5 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,14,8.40,,8.4,60,,6.72,percent of total billed charges,60% of total billed charges,6.72,48,,5.376,percent of total billed charges,48% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,9.8,70,,7.84,percent of total billed charges,70% of total billed charges,6.79,48.48,,5.432,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,6.79,48.48,,5.432,percent of total billed charges,48.48% of total billed charges,9.8,70,,7.84,percent of total billed charges,70% of total billed charges,9.8,70,,7.84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,6.79,48.48,,5.432,percent of total billed charges,48.48% of total billed charges,12.6,90,,10.08,percent of total billed charges,90% of total billed charges,6.79,90,
NOC^ BELLADONNA/PB ELX  [5 ML),,,259,RC,J8499,HCPCS,outpatient,1,UN,114,68.40,,68.4,60,,54.72,percent of total billed charges,60% of total billed charges,54.72,48,,43.776,percent of total billed charges,48% of total billed charges,57,50,,45.6,percent of total billed charges,50% of total billed charges,57,50,,45.6,percent of total billed charges,50% of total billed charges,57,50,,45.6,percent of total billed charges,50% of total billed charges,57,50,,45.6,percent of total billed charges,50% of total billed charges,79.8,70,,63.84,percent of total billed charges,70% of total billed charges,55.27,48.48,,44.216,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,55.27,48.48,,44.216,percent of total billed charges,48.48% of total billed charges,79.8,70,,63.84,percent of total billed charges,70% of total billed charges,79.8,70,,63.84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,55.27,48.48,,44.216,percent of total billed charges,48.48% of total billed charges,102.6,90,,82.08,percent of total billed charges,90% of total billed charges,48.48,102.6,
NOC^ VENLAFAXINE XR CAP 37.5 M,,,259,RC,J8499,HCPCS,outpatient,1,UN,25,15.00,,15,60,,12,percent of total billed charges,60% of total billed charges,12,48,,9.6,percent of total billed charges,48% of total billed charges,12.5,50,,10,percent of total billed charges,50% of total billed charges,12.5,50,,10,percent of total billed charges,50% of total billed charges,12.5,50,,10,percent of total billed charges,50% of total billed charges,12.5,50,,10,percent of total billed charges,50% of total billed charges,17.5,70,,14,percent of total billed charges,70% of total billed charges,12.12,48.48,,9.696,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,12.12,48.48,,9.696,percent of total billed charges,48.48% of total billed charges,17.5,70,,14,percent of total billed charges,70% of total billed charges,17.5,70,,14,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,12.12,48.48,,9.696,percent of total billed charges,48.48% of total billed charges,22.5,90,,18,percent of total billed charges,90% of total billed charges,12.12,90,
NOC^ RALOXIFENE TAB [60 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,90,54.00,,54,60,,43.2,percent of total billed charges,60% of total billed charges,43.2,48,,34.56,percent of total billed charges,48% of total billed charges,45,50,,36,percent of total billed charges,50% of total billed charges,45,50,,36,percent of total billed charges,50% of total billed charges,45,50,,36,percent of total billed charges,50% of total billed charges,45,50,,36,percent of total billed charges,50% of total billed charges,63,70,,50.4,percent of total billed charges,70% of total billed charges,43.63,48.48,,34.904,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,43.63,48.48,,34.904,percent of total billed charges,48.48% of total billed charges,63,70,,50.4,percent of total billed charges,70% of total billed charges,63,70,,50.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,43.63,48.48,,34.904,percent of total billed charges,48.48% of total billed charges,81,90,,64.8,percent of total billed charges,90% of total billed charges,43.63,90,
EPINEPHRINE INJ SYR [1 MG,43601500,CDM,636,RC,J0171,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,0.97,100,,,fee schedule,100% of bcbs custom fee schedule,0.97,100,,,fee schedule,100% of bcbs custom fee schedule,1.08,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
EPSOM SALT 16 OZ,,,250,RC,,,outpatient,,,14,8.40,,8.4,60,,6.72,percent of total billed charges,60% of total billed charges,6.72,48,,5.376,percent of total billed charges,48% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,9.8,70,,7.84,percent of total billed charges,70% of total billed charges,6.79,48.48,,5.432,percent of total billed charges,48.48% of total billed charges,6.79,48.48,,5.432,percent of total billed charges,48.48% of total billed charges,6.79,48.48,,5.432,percent of total billed charges,48.48% of total billed charges,9.8,70,,7.84,percent of total billed charges,70% of total billed charges,9.8,70,,7.84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,6.79,48.48,,5.432,percent of total billed charges,48.48% of total billed charges,12.6,90,,10.08,percent of total billed charges,90% of total billed charges,6.79,90,
RIVASTIGMINE PAT [13.3MG],,,250,RC,,,outpatient,,,68,40.80,,40.8,60,,32.64,percent of total billed charges,60% of total billed charges,32.64,48,,26.112,percent of total billed charges,48% of total billed charges,34,50,,27.2,percent of total billed charges,50% of total billed charges,34,50,,27.2,percent of total billed charges,50% of total billed charges,34,50,,27.2,percent of total billed charges,50% of total billed charges,34,50,,27.2,percent of total billed charges,50% of total billed charges,47.6,70,,38.08,percent of total billed charges,70% of total billed charges,32.97,48.48,,26.376,percent of total billed charges,48.48% of total billed charges,32.97,48.48,,26.376,percent of total billed charges,48.48% of total billed charges,32.97,48.48,,26.376,percent of total billed charges,48.48% of total billed charges,47.6,70,,38.08,percent of total billed charges,70% of total billed charges,47.6,70,,38.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,32.97,48.48,,26.376,percent of total billed charges,48.48% of total billed charges,61.2,90,,48.96,percent of total billed charges,90% of total billed charges,32.97,90,
RIVASTIGMINE PAT [4.6 MG],,,259,RC,J3490,HCPCS,outpatient,1,UN,65,39.00,,39,60,,31.2,percent of total billed charges,60% of total billed charges,31.2,48,,24.96,percent of total billed charges,48% of total billed charges,32.5,50,,26,percent of total billed charges,50% of total billed charges,32.5,50,,26,percent of total billed charges,50% of total billed charges,32.5,50,,26,percent of total billed charges,50% of total billed charges,32.5,50,,26,percent of total billed charges,50% of total billed charges,45.5,70,,36.4,percent of total billed charges,70% of total billed charges,31.51,48.48,,25.208,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,31.51,48.48,,25.208,percent of total billed charges,48.48% of total billed charges,45.5,70,,36.4,percent of total billed charges,70% of total billed charges,45.5,70,,36.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,31.51,48.48,,25.208,percent of total billed charges,48.48% of total billed charges,58.5,90,,46.8,percent of total billed charges,90% of total billed charges,31.51,90,
NOC^ ERYTHROMYCIN TAB [250 MG],,,259,RC,J3490,HCPCS,outpatient,1,UN,36,21.60,,21.6,60,,17.28,percent of total billed charges,60% of total billed charges,17.28,48,,13.824,percent of total billed charges,48% of total billed charges,18,50,,14.4,percent of total billed charges,50% of total billed charges,18,50,,14.4,percent of total billed charges,50% of total billed charges,18,50,,14.4,percent of total billed charges,50% of total billed charges,18,50,,14.4,percent of total billed charges,50% of total billed charges,25.2,70,,20.16,percent of total billed charges,70% of total billed charges,17.45,48.48,,13.96,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,17.45,48.48,,13.96,percent of total billed charges,48.48% of total billed charges,25.2,70,,20.16,percent of total billed charges,70% of total billed charges,25.2,70,,20.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,17.45,48.48,,13.96,percent of total billed charges,48.48% of total billed charges,32.4,90,,25.92,percent of total billed charges,90% of total billed charges,17.45,90,
NOC^ RIVASTIGMINE PAT [9.5 MG],,,259,RC,J3490,HCPCS,outpatient,1,UN,68,40.80,,40.8,60,,32.64,percent of total billed charges,60% of total billed charges,32.64,48,,26.112,percent of total billed charges,48% of total billed charges,34,50,,27.2,percent of total billed charges,50% of total billed charges,34,50,,27.2,percent of total billed charges,50% of total billed charges,34,50,,27.2,percent of total billed charges,50% of total billed charges,34,50,,27.2,percent of total billed charges,50% of total billed charges,47.6,70,,38.08,percent of total billed charges,70% of total billed charges,32.97,48.48,,26.376,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,32.97,48.48,,26.376,percent of total billed charges,48.48% of total billed charges,47.6,70,,38.08,percent of total billed charges,70% of total billed charges,47.6,70,,38.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,32.97,48.48,,26.376,percent of total billed charges,48.48% of total billed charges,61.2,90,,48.96,percent of total billed charges,90% of total billed charges,32.97,90,
ERYPED 200MG/5ML 100ML,,,259,RC,,,outpatient,,,1806,1083.60,,1083.6,60,,866.88,percent of total billed charges,60% of total billed charges,866.88,48,,693.504,percent of total billed charges,48% of total billed charges,903,50,,722.4,percent of total billed charges,50% of total billed charges,903,50,,722.4,percent of total billed charges,50% of total billed charges,903,50,,722.4,percent of total billed charges,50% of total billed charges,903,50,,722.4,percent of total billed charges,50% of total billed charges,1264.2,70,,1011.36,percent of total billed charges,70% of total billed charges,875.55,48.48,,700.44,percent of total billed charges,48.48% of total billed charges,875.55,48.48,,700.44,percent of total billed charges,48.48% of total billed charges,875.55,48.48,,700.44,percent of total billed charges,48.48% of total billed charges,1264.2,70,,1011.36,percent of total billed charges,70% of total billed charges,1264.2,70,,1011.36,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,875.55,48.48,,700.44,percent of total billed charges,48.48% of total billed charges,1625.4,90,,1300.32,percent of total billed charges,90% of total billed charges,48.48,1625.4,
ZIPRASIDONE INJ [20 MG],,,636,RC,J3486,HCPCS,outpatient,1,UN,158,94.80,,94.8,60,,75.84,percent of total billed charges,60% of total billed charges,75.84,48,,60.672,percent of total billed charges,48% of total billed charges,26.26,100,,,fee schedule,100% of bcbs custom fee schedule,26.26,100,,,fee schedule,100% of bcbs custom fee schedule,29.15,111,,,fee schedule,111% of bcbs custom fee schedule,79,50,,63.2,percent of total billed charges,50% of total billed charges,110.6,70,,88.48,percent of total billed charges,70% of total billed charges,76.6,48.48,,61.28,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,76.6,48.48,,61.28,percent of total billed charges,48.48% of total billed charges,110.6,70,,88.48,percent of total billed charges,70% of total billed charges,110.6,70,,88.48,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,76.6,48.48,,61.28,percent of total billed charges,48.48% of total billed charges,142.2,90,,113.76,percent of total billed charges,90% of total billed charges,48.48,142.2,
NOC^ VENLAFAXINE XR CAP 75 MG,,,259,RC,J3490,HCPCS,outpatient,1,UN,28,16.80,,16.8,60,,13.44,percent of total billed charges,60% of total billed charges,13.44,48,,10.752,percent of total billed charges,48% of total billed charges,14,50,,11.2,percent of total billed charges,50% of total billed charges,14,50,,11.2,percent of total billed charges,50% of total billed charges,14,50,,11.2,percent of total billed charges,50% of total billed charges,14,50,,11.2,percent of total billed charges,50% of total billed charges,19.6,70,,15.68,percent of total billed charges,70% of total billed charges,13.57,48.48,,10.856,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,13.57,48.48,,10.856,percent of total billed charges,48.48% of total billed charges,19.6,70,,15.68,percent of total billed charges,70% of total billed charges,19.6,70,,15.68,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,13.57,48.48,,10.856,percent of total billed charges,48.48% of total billed charges,25.2,90,,20.16,percent of total billed charges,90% of total billed charges,13.57,90,
NOC^ MOMETASONE 0.1% CRM,,,259,RC,J3490,HCPCS,outpatient,1,UN,212,127.20,,127.2,60,,101.76,percent of total billed charges,60% of total billed charges,101.76,48,,81.408,percent of total billed charges,48% of total billed charges,106,50,,84.8,percent of total billed charges,50% of total billed charges,106,50,,84.8,percent of total billed charges,50% of total billed charges,106,50,,84.8,percent of total billed charges,50% of total billed charges,106,50,,84.8,percent of total billed charges,50% of total billed charges,148.4,70,,118.72,percent of total billed charges,70% of total billed charges,102.78,48.48,,82.224,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,102.78,48.48,,82.224,percent of total billed charges,48.48% of total billed charges,148.4,70,,118.72,percent of total billed charges,70% of total billed charges,148.4,70,,118.72,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,102.78,48.48,,82.224,percent of total billed charges,48.48% of total billed charges,190.8,90,,152.64,percent of total billed charges,90% of total billed charges,48.48,190.8,
NOC^ VERAPAMIL INJ [2.5 MG/ML],,,250,RC,J3490,HCPCS,outpatient,1,UN,70,42.00,,42,60,,33.6,percent of total billed charges,60% of total billed charges,33.6,48,,26.88,percent of total billed charges,48% of total billed charges,35,50,,28,percent of total billed charges,50% of total billed charges,35,50,,28,percent of total billed charges,50% of total billed charges,35,50,,28,percent of total billed charges,50% of total billed charges,35,50,,28,percent of total billed charges,50% of total billed charges,49,70,,39.2,percent of total billed charges,70% of total billed charges,33.94,48.48,,27.152,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,33.94,48.48,,27.152,percent of total billed charges,48.48% of total billed charges,49,70,,39.2,percent of total billed charges,70% of total billed charges,49,70,,39.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,33.94,48.48,,27.152,percent of total billed charges,48.48% of total billed charges,63,90,,50.4,percent of total billed charges,90% of total billed charges,33.94,90,
NOC^ ZINC OXIDE PASTE [60GM],,,257,RC,J3490,HCPCS,outpatient,1,UN,16,9.60,,9.6,60,,7.68,percent of total billed charges,60% of total billed charges,7.68,48,,6.144,percent of total billed charges,48% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,11.2,70,,8.96,percent of total billed charges,70% of total billed charges,7.76,48.48,,6.208,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,7.76,48.48,,6.208,percent of total billed charges,48.48% of total billed charges,11.2,70,,8.96,percent of total billed charges,70% of total billed charges,11.2,70,,8.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,7.76,48.48,,6.208,percent of total billed charges,48.48% of total billed charges,14.4,90,,11.52,percent of total billed charges,90% of total billed charges,7.76,90,
BUMETANIDE INJ [0.25 MG/M,,,636,RC,S0171,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,0.96,100,,,fee schedule,100% of bcbs custom fee schedule,0.96,100,,,fee schedule,100% of bcbs custom fee schedule,1.07,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
CLARITHROMYCIN TAB 250MG,,,259,RC,,,outpatient,,,24,14.40,,14.4,60,,11.52,percent of total billed charges,60% of total billed charges,11.52,48,,9.216,percent of total billed charges,48% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,21.6,90,,17.28,percent of total billed charges,90% of total billed charges,11.64,90,
CLARITHROMYCIN SUSP 250MG (100 ML),,,259,RC,J8499,HCPCS,outpatient,1,UN,795,477.00,,477,60,,381.6,percent of total billed charges,60% of total billed charges,381.6,48,,305.28,percent of total billed charges,48% of total billed charges,397.5,50,,318,percent of total billed charges,50% of total billed charges,397.5,50,,318,percent of total billed charges,50% of total billed charges,397.5,50,,318,percent of total billed charges,50% of total billed charges,397.5,50,,318,percent of total billed charges,50% of total billed charges,556.5,70,,445.2,percent of total billed charges,70% of total billed charges,385.42,48.48,,308.336,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,385.42,48.48,,308.336,percent of total billed charges,48.48% of total billed charges,556.5,70,,445.2,percent of total billed charges,70% of total billed charges,556.5,70,,445.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,385.42,48.48,,308.336,percent of total billed charges,48.48% of total billed charges,715.5,90,,572.4,percent of total billed charges,90% of total billed charges,48.48,715.5,
AURALGAN OTIC DROPS 10CC,,,259,RC,,,outpatient,,,44,26.40,,26.4,60,,21.12,percent of total billed charges,60% of total billed charges,21.12,48,,16.896,percent of total billed charges,48% of total billed charges,22,50,,17.6,percent of total billed charges,50% of total billed charges,22,50,,17.6,percent of total billed charges,50% of total billed charges,22,50,,17.6,percent of total billed charges,50% of total billed charges,22,50,,17.6,percent of total billed charges,50% of total billed charges,30.8,70,,24.64,percent of total billed charges,70% of total billed charges,21.33,48.48,,17.064,percent of total billed charges,48.48% of total billed charges,21.33,48.48,,17.064,percent of total billed charges,48.48% of total billed charges,21.33,48.48,,17.064,percent of total billed charges,48.48% of total billed charges,30.8,70,,24.64,percent of total billed charges,70% of total billed charges,30.8,70,,24.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,21.33,48.48,,17.064,percent of total billed charges,48.48% of total billed charges,39.6,90,,31.68,percent of total billed charges,90% of total billed charges,21.33,90,
NOC^ ALBUMIN HUMAN 25% INJ 100,,,250,RC,J3490,HCPCS,outpatient,1,UN,359,215.40,,215.4,60,,172.32,percent of total billed charges,60% of total billed charges,172.32,48,,137.856,percent of total billed charges,48% of total billed charges,179.5,50,,143.6,percent of total billed charges,50% of total billed charges,179.5,50,,143.6,percent of total billed charges,50% of total billed charges,179.5,50,,143.6,percent of total billed charges,50% of total billed charges,179.5,50,,143.6,percent of total billed charges,50% of total billed charges,251.3,70,,201.04,percent of total billed charges,70% of total billed charges,174.04,48.48,,139.232,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,174.04,48.48,,139.232,percent of total billed charges,48.48% of total billed charges,251.3,70,,201.04,percent of total billed charges,70% of total billed charges,251.3,70,,201.04,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,174.04,48.48,,139.232,percent of total billed charges,48.48% of total billed charges,323.1,90,,258.48,percent of total billed charges,90% of total billed charges,48.48,323.1,
NOC^ EMOLLIENT/ SKIN CLEANSER,,,257,RC,J3490,HCPCS,outpatient,1,UN,35,21.00,,21,60,,16.8,percent of total billed charges,60% of total billed charges,16.8,48,,13.44,percent of total billed charges,48% of total billed charges,17.5,50,,14,percent of total billed charges,50% of total billed charges,17.5,50,,14,percent of total billed charges,50% of total billed charges,17.5,50,,14,percent of total billed charges,50% of total billed charges,17.5,50,,14,percent of total billed charges,50% of total billed charges,24.5,70,,19.6,percent of total billed charges,70% of total billed charges,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,24.5,70,,19.6,percent of total billed charges,70% of total billed charges,24.5,70,,19.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,31.5,90,,25.2,percent of total billed charges,90% of total billed charges,16.97,90,
FERROUS SULF LIQ [300mg/5ml],,,257,RC,J8499,HCPCS,outpatient,1,UN,18,10.80,,10.8,60,,8.64,percent of total billed charges,60% of total billed charges,8.64,48,,6.912,percent of total billed charges,48% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,12.6,70,,10.08,percent of total billed charges,70% of total billed charges,8.73,48.48,,6.984,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,8.73,48.48,,6.984,percent of total billed charges,48.48% of total billed charges,12.6,70,,10.08,percent of total billed charges,70% of total billed charges,12.6,70,,10.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,8.73,48.48,,6.984,percent of total billed charges,48.48% of total billed charges,16.2,90,,12.96,percent of total billed charges,90% of total billed charges,8.73,90,
NOC^ BACITRACIN OPTH OIN 3.5G,,,259,RC,J3490,HCPCS,outpatient,1,UN,519,311.40,,311.4,60,,249.12,percent of total billed charges,60% of total billed charges,249.12,48,,199.296,percent of total billed charges,48% of total billed charges,259.5,50,,207.6,percent of total billed charges,50% of total billed charges,259.5,50,,207.6,percent of total billed charges,50% of total billed charges,259.5,50,,207.6,percent of total billed charges,50% of total billed charges,259.5,50,,207.6,percent of total billed charges,50% of total billed charges,363.3,70,,290.64,percent of total billed charges,70% of total billed charges,251.61,48.48,,201.288,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,251.61,48.48,,201.288,percent of total billed charges,48.48% of total billed charges,363.3,70,,290.64,percent of total billed charges,70% of total billed charges,363.3,70,,290.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,251.61,48.48,,201.288,percent of total billed charges,48.48% of total billed charges,467.1,90,,373.68,percent of total billed charges,90% of total billed charges,48.48,467.1,
NOC^ PIOGLITAZONE TAB [45 MG],,,259,RC,J3490,HCPCS,outpatient,1,UN,57,34.20,,34.2,60,,27.36,percent of total billed charges,60% of total billed charges,27.36,48,,21.888,percent of total billed charges,48% of total billed charges,28.5,50,,22.8,percent of total billed charges,50% of total billed charges,28.5,50,,22.8,percent of total billed charges,50% of total billed charges,28.5,50,,22.8,percent of total billed charges,50% of total billed charges,28.5,50,,22.8,percent of total billed charges,50% of total billed charges,39.9,70,,31.92,percent of total billed charges,70% of total billed charges,27.63,48.48,,22.104,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,27.63,48.48,,22.104,percent of total billed charges,48.48% of total billed charges,39.9,70,,31.92,percent of total billed charges,70% of total billed charges,39.9,70,,31.92,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,27.63,48.48,,22.104,percent of total billed charges,48.48% of total billed charges,51.3,90,,41.04,percent of total billed charges,90% of total billed charges,27.63,90,
FOSPHENYTOIN INJ [100 MG/,,,250,RC,Q2009,HCPCS,outpatient,1,UN,161,96.60,,96.6,60,,77.28,percent of total billed charges,60% of total billed charges,77.28,48,,61.824,percent of total billed charges,48% of total billed charges,5.47,100,,,fee schedule,100% of bcbs custom fee schedule,5.47,100,,,fee schedule,100% of bcbs custom fee schedule,6.07,111,,,fee schedule,111% of bcbs custom fee schedule,80.5,50,,64.4,percent of total billed charges,50% of total billed charges,112.7,70,,90.16,percent of total billed charges,70% of total billed charges,78.05,48.48,,62.44,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,78.05,48.48,,62.44,percent of total billed charges,48.48% of total billed charges,112.7,70,,90.16,percent of total billed charges,70% of total billed charges,112.7,70,,90.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,78.05,48.48,,62.44,percent of total billed charges,48.48% of total billed charges,144.9,90,,115.92,percent of total billed charges,90% of total billed charges,48.48,144.9,
NOC^ L-METHYLFOL/ MCOBAL/ ACYS,,,251,RC,J8499,HCPCS,outpatient,1,UN,29,17.40,,17.4,60,,13.92,percent of total billed charges,60% of total billed charges,13.92,48,,11.136,percent of total billed charges,48% of total billed charges,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,20.3,70,,16.24,percent of total billed charges,70% of total billed charges,14.06,48.48,,11.248,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,14.06,48.48,,11.248,percent of total billed charges,48.48% of total billed charges,20.3,70,,16.24,percent of total billed charges,70% of total billed charges,20.3,70,,16.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,14.06,48.48,,11.248,percent of total billed charges,48.48% of total billed charges,26.1,90,,20.88,percent of total billed charges,90% of total billed charges,14.06,90,
NOC^ MUPIROCIN OIN 2%,,,259,RC,J3490,HCPCS,outpatient,1,UN,45,27.00,,27,60,,21.6,percent of total billed charges,60% of total billed charges,21.6,48,,17.28,percent of total billed charges,48% of total billed charges,22.5,50,,18,percent of total billed charges,50% of total billed charges,22.5,50,,18,percent of total billed charges,50% of total billed charges,22.5,50,,18,percent of total billed charges,50% of total billed charges,22.5,50,,18,percent of total billed charges,50% of total billed charges,31.5,70,,25.2,percent of total billed charges,70% of total billed charges,21.82,48.48,,17.456,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,21.82,48.48,,17.456,percent of total billed charges,48.48% of total billed charges,31.5,70,,25.2,percent of total billed charges,70% of total billed charges,31.5,70,,25.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,21.82,48.48,,17.456,percent of total billed charges,48.48% of total billed charges,40.5,90,,32.4,percent of total billed charges,90% of total billed charges,21.82,90,
NOC^ CLEOCIN PREMX [600MG/50ML,,,636,RC,J0736,HCPCS,outpatient,2,UN,60,36.00,,36,60,,28.8,percent of total billed charges,60% of total billed charges,28.8,48,,23.04,percent of total billed charges,48% of total billed charges,30,50,,24,percent of total billed charges,50% of total billed charges,30,50,,24,percent of total billed charges,50% of total billed charges,30,50,,24,percent of total billed charges,50% of total billed charges,30,50,,24,percent of total billed charges,50% of total billed charges,42,70,,33.6,percent of total billed charges,70% of total billed charges,29.09,48.48,,23.272,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,29.09,48.48,,23.272,percent of total billed charges,48.48% of total billed charges,42,70,,33.6,percent of total billed charges,70% of total billed charges,42,70,,33.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,29.09,48.48,,23.272,percent of total billed charges,48.48% of total billed charges,54,90,,43.2,percent of total billed charges,90% of total billed charges,29.09,90,
NOC^ TAMSULOSIN CAP [0.4 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,17,10.20,,10.2,60,,8.16,percent of total billed charges,60% of total billed charges,8.16,48,,6.528,percent of total billed charges,48% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,11.9,70,,9.52,percent of total billed charges,70% of total billed charges,8.24,48.48,,6.592,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,8.24,48.48,,6.592,percent of total billed charges,48.48% of total billed charges,11.9,70,,9.52,percent of total billed charges,70% of total billed charges,11.9,70,,9.52,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,8.24,48.48,,6.592,percent of total billed charges,48.48% of total billed charges,15.3,90,,12.24,percent of total billed charges,90% of total billed charges,8.24,90,
NOC^ ALENDRONATE TAB 70 MG,,,259,RC,J3490,HCPCS,outpatient,1,UN,82,49.20,,49.2,60,,39.36,percent of total billed charges,60% of total billed charges,39.36,48,,31.488,percent of total billed charges,48% of total billed charges,41,50,,32.8,percent of total billed charges,50% of total billed charges,41,50,,32.8,percent of total billed charges,50% of total billed charges,41,50,,32.8,percent of total billed charges,50% of total billed charges,41,50,,32.8,percent of total billed charges,50% of total billed charges,57.4,70,,45.92,percent of total billed charges,70% of total billed charges,39.75,48.48,,31.8,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,39.75,48.48,,31.8,percent of total billed charges,48.48% of total billed charges,57.4,70,,45.92,percent of total billed charges,70% of total billed charges,57.4,70,,45.92,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,39.75,48.48,,31.8,percent of total billed charges,48.48% of total billed charges,73.8,90,,59.04,percent of total billed charges,90% of total billed charges,39.75,90,
NOC^ ALENDRONATE/VITD TAB 70MG,,,259,RC,J8499,HCPCS,outpatient,1,UN,145,87.00,,87,60,,69.6,percent of total billed charges,60% of total billed charges,69.6,48,,55.68,percent of total billed charges,48% of total billed charges,72.5,50,,58,percent of total billed charges,50% of total billed charges,72.5,50,,58,percent of total billed charges,50% of total billed charges,72.5,50,,58,percent of total billed charges,50% of total billed charges,72.5,50,,58,percent of total billed charges,50% of total billed charges,101.5,70,,81.2,percent of total billed charges,70% of total billed charges,70.3,48.48,,56.24,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,70.3,48.48,,56.24,percent of total billed charges,48.48% of total billed charges,101.5,70,,81.2,percent of total billed charges,70% of total billed charges,101.5,70,,81.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,70.3,48.48,,56.24,percent of total billed charges,48.48% of total billed charges,130.5,90,,104.4,percent of total billed charges,90% of total billed charges,48.48,130.5,
METRONIDAZOL IV BAG 500MG,,,636,RC,J1836,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
INFLUENZA VACC NASAL,,,636,RC,90660,HCPCS,outpatient,1,UN,57,34.20,,34.2,60,,27.36,percent of total billed charges,60% of total billed charges,27.36,48,,21.888,percent of total billed charges,48% of total billed charges,23.46,100,,,fee schedule,100% of bcbs custom fee schedule,23.46,100,,,fee schedule,100% of bcbs custom fee schedule,26.04,111,,,fee schedule,111% of bcbs custom fee schedule,28.5,50,,22.8,percent of total billed charges,50% of total billed charges,39.9,70,,31.92,percent of total billed charges,70% of total billed charges,27.63,48.48,,22.104,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,27.63,48.48,,22.104,percent of total billed charges,48.48% of total billed charges,39.9,70,,31.92,percent of total billed charges,70% of total billed charges,39.9,70,,31.92,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,27.63,48.48,,22.104,percent of total billed charges,48.48% of total billed charges,51.3,90,,41.04,percent of total billed charges,90% of total billed charges,27.63,90,
FORTAZ 1GM/ D5 50 ML PRMX,,,636,RC,J0713,HCPCS,outpatient,1,UN,75,45.00,,45,60,,36,percent of total billed charges,60% of total billed charges,36,48,,28.8,percent of total billed charges,48% of total billed charges,2.15,100,,,fee schedule,100% of bcbs custom fee schedule,2.15,100,,,fee schedule,100% of bcbs custom fee schedule,2.39,111,,,fee schedule,111% of bcbs custom fee schedule,37.5,50,,30,percent of total billed charges,50% of total billed charges,52.5,70,,42,percent of total billed charges,70% of total billed charges,36.36,48.48,,29.088,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,36.36,48.48,,29.088,percent of total billed charges,48.48% of total billed charges,52.5,70,,42,percent of total billed charges,70% of total billed charges,52.5,70,,42,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,36.36,48.48,,29.088,percent of total billed charges,48.48% of total billed charges,67.5,90,,54,percent of total billed charges,90% of total billed charges,36.36,90,
CEFTAZIDIME INJ 2 GM,,,636,RC,J0713,HCPCS,outpatient,1,UN,25,15.00,,15,60,,12,percent of total billed charges,60% of total billed charges,12,48,,9.6,percent of total billed charges,48% of total billed charges,2.15,100,,,fee schedule,100% of bcbs custom fee schedule,2.15,100,,,fee schedule,100% of bcbs custom fee schedule,2.39,111,,,fee schedule,111% of bcbs custom fee schedule,12.5,50,,10,percent of total billed charges,50% of total billed charges,17.5,70,,14,percent of total billed charges,70% of total billed charges,12.12,48.48,,9.696,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,12.12,48.48,,9.696,percent of total billed charges,48.48% of total billed charges,17.5,70,,14,percent of total billed charges,70% of total billed charges,17.5,70,,14,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,12.12,48.48,,9.696,percent of total billed charges,48.48% of total billed charges,22.5,90,,18,percent of total billed charges,90% of total billed charges,12.12,90,
MAXITROL OPTH OINT 3.5GM,,,259,RC,,,outpatient,,,87,52.20,,52.2,60,,41.76,percent of total billed charges,60% of total billed charges,41.76,48,,33.408,percent of total billed charges,48% of total billed charges,43.5,50,,34.8,percent of total billed charges,50% of total billed charges,43.5,50,,34.8,percent of total billed charges,50% of total billed charges,43.5,50,,34.8,percent of total billed charges,50% of total billed charges,43.5,50,,34.8,percent of total billed charges,50% of total billed charges,60.9,70,,48.72,percent of total billed charges,70% of total billed charges,42.18,48.48,,33.744,percent of total billed charges,48.48% of total billed charges,42.18,48.48,,33.744,percent of total billed charges,48.48% of total billed charges,42.18,48.48,,33.744,percent of total billed charges,48.48% of total billed charges,60.9,70,,48.72,percent of total billed charges,70% of total billed charges,60.9,70,,48.72,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,42.18,48.48,,33.744,percent of total billed charges,48.48% of total billed charges,78.3,90,,62.64,percent of total billed charges,90% of total billed charges,42.18,90,
FENTANYL INJ 100MCG/2ML,,,636,RC,J3010,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,0.86,100,,,fee schedule,100% of bcbs custom fee schedule,0.86,100,,,fee schedule,100% of bcbs custom fee schedule,0.95,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
NOC^ HYDROCORTISONE 2.5%  CRM,,,259,RC,J3490,HCPCS,outpatient,1,UN,44,26.40,,26.4,60,,21.12,percent of total billed charges,60% of total billed charges,21.12,48,,16.896,percent of total billed charges,48% of total billed charges,22,50,,17.6,percent of total billed charges,50% of total billed charges,22,50,,17.6,percent of total billed charges,50% of total billed charges,22,50,,17.6,percent of total billed charges,50% of total billed charges,22,50,,17.6,percent of total billed charges,50% of total billed charges,30.8,70,,24.64,percent of total billed charges,70% of total billed charges,21.33,48.48,,17.064,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,21.33,48.48,,17.064,percent of total billed charges,48.48% of total billed charges,30.8,70,,24.64,percent of total billed charges,70% of total billed charges,30.8,70,,24.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,21.33,48.48,,17.064,percent of total billed charges,48.48% of total billed charges,39.6,90,,31.68,percent of total billed charges,90% of total billed charges,21.33,90,
NOC^ PROMETHAZINE SUPP 25 MG,,,259,RC,J3490,HCPCS,outpatient,1,UN,71,42.60,,42.6,60,,34.08,percent of total billed charges,60% of total billed charges,34.08,48,,27.264,percent of total billed charges,48% of total billed charges,35.5,50,,28.4,percent of total billed charges,50% of total billed charges,35.5,50,,28.4,percent of total billed charges,50% of total billed charges,35.5,50,,28.4,percent of total billed charges,50% of total billed charges,35.5,50,,28.4,percent of total billed charges,50% of total billed charges,49.7,70,,39.76,percent of total billed charges,70% of total billed charges,34.42,48.48,,27.536,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,34.42,48.48,,27.536,percent of total billed charges,48.48% of total billed charges,49.7,70,,39.76,percent of total billed charges,70% of total billed charges,49.7,70,,39.76,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,34.42,48.48,,27.536,percent of total billed charges,48.48% of total billed charges,63.9,90,,51.12,percent of total billed charges,90% of total billed charges,34.42,90,
NOC^ PROMETHAZINE SUPP 50 MG,,,259,RC,J3490,HCPCS,outpatient,1,UN,144,86.40,,86.4,60,,69.12,percent of total billed charges,60% of total billed charges,69.12,48,,55.296,percent of total billed charges,48% of total billed charges,72,50,,57.6,percent of total billed charges,50% of total billed charges,72,50,,57.6,percent of total billed charges,50% of total billed charges,72,50,,57.6,percent of total billed charges,50% of total billed charges,72,50,,57.6,percent of total billed charges,50% of total billed charges,100.8,70,,80.64,percent of total billed charges,70% of total billed charges,69.81,48.48,,55.848,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,69.81,48.48,,55.848,percent of total billed charges,48.48% of total billed charges,100.8,70,,80.64,percent of total billed charges,70% of total billed charges,100.8,70,,80.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,69.81,48.48,,55.848,percent of total billed charges,48.48% of total billed charges,129.6,90,,103.68,percent of total billed charges,90% of total billed charges,48.48,129.6,
NOC^ CELEBREX CAP (100 MG),,,259,RC,J8499,HCPCS,outpatient,1,UN,19,11.40,,11.4,60,,9.12,percent of total billed charges,60% of total billed charges,9.12,48,,7.296,percent of total billed charges,48% of total billed charges,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,13.3,70,,10.64,percent of total billed charges,70% of total billed charges,9.21,48.48,,7.368,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.21,48.48,,7.368,percent of total billed charges,48.48% of total billed charges,13.3,70,,10.64,percent of total billed charges,70% of total billed charges,13.3,70,,10.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.21,48.48,,7.368,percent of total billed charges,48.48% of total billed charges,17.1,90,,13.68,percent of total billed charges,90% of total billed charges,9.21,90,
OSELTAMIVIR CAP 75MG (10ct),,,259,RC,J8499,HCPCS,outpatient,1,UN,55,33.00,,33,60,,26.4,percent of total billed charges,60% of total billed charges,26.4,48,,21.12,percent of total billed charges,48% of total billed charges,27.5,50,,22,percent of total billed charges,50% of total billed charges,27.5,50,,22,percent of total billed charges,50% of total billed charges,27.5,50,,22,percent of total billed charges,50% of total billed charges,27.5,50,,22,percent of total billed charges,50% of total billed charges,38.5,70,,30.8,percent of total billed charges,70% of total billed charges,26.66,48.48,,21.328,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,26.66,48.48,,21.328,percent of total billed charges,48.48% of total billed charges,38.5,70,,30.8,percent of total billed charges,70% of total billed charges,38.5,70,,30.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,26.66,48.48,,21.328,percent of total billed charges,48.48% of total billed charges,49.5,90,,39.6,percent of total billed charges,90% of total billed charges,26.66,90,
NOC^ OSELTAMIVIR SOL 6 MG/ML 6,,,259,RC,J3490,HCPCS,outpatient,1,UN,12,7.20,,7.2,60,,5.76,percent of total billed charges,60% of total billed charges,5.76,48,,4.608,percent of total billed charges,48% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,8.4,70,,6.72,percent of total billed charges,70% of total billed charges,5.82,48.48,,4.656,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,5.82,48.48,,4.656,percent of total billed charges,48.48% of total billed charges,8.4,70,,6.72,percent of total billed charges,70% of total billed charges,8.4,70,,6.72,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,5.82,48.48,,4.656,percent of total billed charges,48.48% of total billed charges,10.8,90,,8.64,percent of total billed charges,90% of total billed charges,5.82,90,
NOC^ PIOGLITAZONE TAB [30 MG],,,259,RC,J3490,HCPCS,outpatient,1,UN,35,21.00,,21,60,,16.8,percent of total billed charges,60% of total billed charges,16.8,48,,13.44,percent of total billed charges,48% of total billed charges,17.5,50,,14,percent of total billed charges,50% of total billed charges,17.5,50,,14,percent of total billed charges,50% of total billed charges,17.5,50,,14,percent of total billed charges,50% of total billed charges,17.5,50,,14,percent of total billed charges,50% of total billed charges,24.5,70,,19.6,percent of total billed charges,70% of total billed charges,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,24.5,70,,19.6,percent of total billed charges,70% of total billed charges,24.5,70,,19.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,31.5,90,,25.2,percent of total billed charges,90% of total billed charges,16.97,90,
NOC^ GENTAMICIN 0.3% EYE DRP,,,259,RC,J3490,HCPCS,outpatient,1,UN,39,23.40,,23.4,60,,18.72,percent of total billed charges,60% of total billed charges,18.72,48,,14.976,percent of total billed charges,48% of total billed charges,19.5,50,,15.6,percent of total billed charges,50% of total billed charges,19.5,50,,15.6,percent of total billed charges,50% of total billed charges,19.5,50,,15.6,percent of total billed charges,50% of total billed charges,19.5,50,,15.6,percent of total billed charges,50% of total billed charges,27.3,70,,21.84,percent of total billed charges,70% of total billed charges,18.91,48.48,,15.128,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,18.91,48.48,,15.128,percent of total billed charges,48.48% of total billed charges,27.3,70,,21.84,percent of total billed charges,70% of total billed charges,27.3,70,,21.84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,18.91,48.48,,15.128,percent of total billed charges,48.48% of total billed charges,35.1,90,,28.08,percent of total billed charges,90% of total billed charges,18.91,90,
MULTIVITAMIN LIQ 15 ML,,,257,RC,J3490,HCPCS,outpatient,1,UN,11,6.60,,6.6,60,,5.28,percent of total billed charges,60% of total billed charges,5.28,48,,4.224,percent of total billed charges,48% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,9.9,90,,7.92,percent of total billed charges,90% of total billed charges,5.33,90,
MEPERIDINE INJ [50 MG/ML],,,636,RC,J2180,HCPCS,outpatient,1,UN,64,38.40,,38.4,60,,30.72,percent of total billed charges,60% of total billed charges,30.72,48,,24.576,percent of total billed charges,48% of total billed charges,4.17,100,,,fee schedule,100% of bcbs custom fee schedule,4.17,100,,,fee schedule,100% of bcbs custom fee schedule,4.63,111,,,fee schedule,111% of bcbs custom fee schedule,32,50,,25.6,percent of total billed charges,50% of total billed charges,44.8,70,,35.84,percent of total billed charges,70% of total billed charges,31.03,48.48,,24.824,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,31.03,48.48,,24.824,percent of total billed charges,48.48% of total billed charges,44.8,70,,35.84,percent of total billed charges,70% of total billed charges,44.8,70,,35.84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,31.03,48.48,,24.824,percent of total billed charges,48.48% of total billed charges,57.6,90,,46.08,percent of total billed charges,90% of total billed charges,31.03,90,
NOC^ GI COCTAIL SUSP,,,259,RC,J3490,HCPCS,outpatient,1,UN,25,15.00,,15,60,,12,percent of total billed charges,60% of total billed charges,12,48,,9.6,percent of total billed charges,48% of total billed charges,12.5,50,,10,percent of total billed charges,50% of total billed charges,12.5,50,,10,percent of total billed charges,50% of total billed charges,12.5,50,,10,percent of total billed charges,50% of total billed charges,12.5,50,,10,percent of total billed charges,50% of total billed charges,17.5,70,,14,percent of total billed charges,70% of total billed charges,12.12,48.48,,9.696,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,12.12,48.48,,9.696,percent of total billed charges,48.48% of total billed charges,17.5,70,,14,percent of total billed charges,70% of total billed charges,17.5,70,,14,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,12.12,48.48,,9.696,percent of total billed charges,48.48% of total billed charges,22.5,90,,18,percent of total billed charges,90% of total billed charges,12.12,90,
NOC^ TIAGABINE TAB [4 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,22,13.20,,13.2,60,,10.56,percent of total billed charges,60% of total billed charges,10.56,48,,8.448,percent of total billed charges,48% of total billed charges,11,50,,8.8,percent of total billed charges,50% of total billed charges,11,50,,8.8,percent of total billed charges,50% of total billed charges,11,50,,8.8,percent of total billed charges,50% of total billed charges,11,50,,8.8,percent of total billed charges,50% of total billed charges,15.4,70,,12.32,percent of total billed charges,70% of total billed charges,10.67,48.48,,8.536,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,10.67,48.48,,8.536,percent of total billed charges,48.48% of total billed charges,15.4,70,,12.32,percent of total billed charges,70% of total billed charges,15.4,70,,12.32,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,10.67,48.48,,8.536,percent of total billed charges,48.48% of total billed charges,19.8,90,,15.84,percent of total billed charges,90% of total billed charges,10.67,90,
GENTAMICIN 0.1% OIN,,,259,RC,J3490,HCPCS,outpatient,1,UN,15,9.00,,9,60,,7.2,percent of total billed charges,60% of total billed charges,7.2,48,,5.76,percent of total billed charges,48% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,13.5,90,,10.8,percent of total billed charges,90% of total billed charges,7.27,90,
NOC^ CELEBREX CAP (200 MG),,,259,RC,J8499,HCPCS,outpatient,1,UN,26,15.60,,15.6,60,,12.48,percent of total billed charges,60% of total billed charges,12.48,48,,9.984,percent of total billed charges,48% of total billed charges,13,50,,10.4,percent of total billed charges,50% of total billed charges,13,50,,10.4,percent of total billed charges,50% of total billed charges,13,50,,10.4,percent of total billed charges,50% of total billed charges,13,50,,10.4,percent of total billed charges,50% of total billed charges,18.2,70,,14.56,percent of total billed charges,70% of total billed charges,12.6,48.48,,10.08,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,12.6,48.48,,10.08,percent of total billed charges,48.48% of total billed charges,18.2,70,,14.56,percent of total billed charges,70% of total billed charges,18.2,70,,14.56,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,12.6,48.48,,10.08,percent of total billed charges,48.48% of total billed charges,23.4,90,,18.72,percent of total billed charges,90% of total billed charges,12.6,90,
GLUCAGON SUBQ INJ [1 MG],,,636,RC,J1610,HCPCS,outpatient,1,UN,1348,808.80,,808.8,60,,647.04,percent of total billed charges,60% of total billed charges,647.04,48,,517.632,percent of total billed charges,48% of total billed charges,232.97,100,,,fee schedule,100% of bcbs custom fee schedule,232.97,100,,,fee schedule,100% of bcbs custom fee schedule,258.6,111,,,fee schedule,111% of bcbs custom fee schedule,674,50,,539.2,percent of total billed charges,50% of total billed charges,943.6,70,,754.88,percent of total billed charges,70% of total billed charges,653.51,48.48,,522.808,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,653.51,48.48,,522.808,percent of total billed charges,48.48% of total billed charges,943.6,70,,754.88,percent of total billed charges,70% of total billed charges,943.6,70,,754.88,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,653.51,48.48,,522.808,percent of total billed charges,48.48% of total billed charges,1213.2,90,,970.56,percent of total billed charges,90% of total billed charges,48.48,1213.2,
NOC^ BAL PERU/ TRYP/ CAS OIL S,,,259,RC,J3490,HCPCS,outpatient,1,UN,62,37.20,,37.2,60,,29.76,percent of total billed charges,60% of total billed charges,29.76,48,,23.808,percent of total billed charges,48% of total billed charges,31,50,,24.8,percent of total billed charges,50% of total billed charges,31,50,,24.8,percent of total billed charges,50% of total billed charges,31,50,,24.8,percent of total billed charges,50% of total billed charges,31,50,,24.8,percent of total billed charges,50% of total billed charges,43.4,70,,34.72,percent of total billed charges,70% of total billed charges,30.06,48.48,,24.048,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,30.06,48.48,,24.048,percent of total billed charges,48.48% of total billed charges,43.4,70,,34.72,percent of total billed charges,70% of total billed charges,43.4,70,,34.72,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,30.06,48.48,,24.048,percent of total billed charges,48.48% of total billed charges,55.8,90,,44.64,percent of total billed charges,90% of total billed charges,30.06,90,
GRANULEX SPRAY 1-APPL,,,259,RC,,,outpatient,,,61,36.60,,36.6,60,,29.28,percent of total billed charges,60% of total billed charges,29.28,48,,23.424,percent of total billed charges,48% of total billed charges,30.5,50,,24.4,percent of total billed charges,50% of total billed charges,30.5,50,,24.4,percent of total billed charges,50% of total billed charges,30.5,50,,24.4,percent of total billed charges,50% of total billed charges,30.5,50,,24.4,percent of total billed charges,50% of total billed charges,42.7,70,,34.16,percent of total billed charges,70% of total billed charges,29.57,48.48,,23.656,percent of total billed charges,48.48% of total billed charges,29.57,48.48,,23.656,percent of total billed charges,48.48% of total billed charges,29.57,48.48,,23.656,percent of total billed charges,48.48% of total billed charges,42.7,70,,34.16,percent of total billed charges,70% of total billed charges,42.7,70,,34.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,29.57,48.48,,23.656,percent of total billed charges,48.48% of total billed charges,54.9,90,,43.92,percent of total billed charges,90% of total billed charges,29.57,90,
NOC^ GENTAMICIN 0.3% EYE OIN,,,259,RC,J3490,HCPCS,outpatient,1,UN,79,47.40,,47.4,60,,37.92,percent of total billed charges,60% of total billed charges,37.92,48,,30.336,percent of total billed charges,48% of total billed charges,39.5,50,,31.6,percent of total billed charges,50% of total billed charges,39.5,50,,31.6,percent of total billed charges,50% of total billed charges,39.5,50,,31.6,percent of total billed charges,50% of total billed charges,39.5,50,,31.6,percent of total billed charges,50% of total billed charges,55.3,70,,44.24,percent of total billed charges,70% of total billed charges,38.3,48.48,,30.64,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,38.3,48.48,,30.64,percent of total billed charges,48.48% of total billed charges,55.3,70,,44.24,percent of total billed charges,70% of total billed charges,55.3,70,,44.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,38.3,48.48,,30.64,percent of total billed charges,48.48% of total billed charges,71.1,90,,56.88,percent of total billed charges,90% of total billed charges,38.3,90,
NOC^ CITALOPRAM TAB [20 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,11,6.60,,6.6,60,,5.28,percent of total billed charges,60% of total billed charges,5.28,48,,4.224,percent of total billed charges,48% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,9.9,90,,7.92,percent of total billed charges,90% of total billed charges,5.33,90,
NOC^ DONEPEZIL TAB [10 MG],,,259,RC,J3490,HCPCS,outpatient,1,UN,53,31.80,,31.8,60,,25.44,percent of total billed charges,60% of total billed charges,25.44,48,,20.352,percent of total billed charges,48% of total billed charges,26.5,50,,21.2,percent of total billed charges,50% of total billed charges,26.5,50,,21.2,percent of total billed charges,50% of total billed charges,26.5,50,,21.2,percent of total billed charges,50% of total billed charges,26.5,50,,21.2,percent of total billed charges,50% of total billed charges,37.1,70,,29.68,percent of total billed charges,70% of total billed charges,25.69,48.48,,20.552,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,25.69,48.48,,20.552,percent of total billed charges,48.48% of total billed charges,37.1,70,,29.68,percent of total billed charges,70% of total billed charges,37.1,70,,29.68,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,25.69,48.48,,20.552,percent of total billed charges,48.48% of total billed charges,47.7,90,,38.16,percent of total billed charges,90% of total billed charges,25.69,90,
LORAZEPAM INJ [2 MG/ML],,,636,RC,J2060,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,0.83,100,,,fee schedule,100% of bcbs custom fee schedule,0.83,100,,,fee schedule,100% of bcbs custom fee schedule,0.92,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
TRIAMCINOLONE VL [40 MG/M,43601525,CDM,250,RC,J3301,HCPCS,outpatient,1,UN,41,24.60,,24.6,60,,19.68,percent of total billed charges,60% of total billed charges,19.68,48,,15.744,percent of total billed charges,48% of total billed charges,1.46,100,,,fee schedule,100% of bcbs custom fee schedule,1.46,100,,,fee schedule,100% of bcbs custom fee schedule,1.62,111,,,fee schedule,111% of bcbs custom fee schedule,20.5,50,,16.4,percent of total billed charges,50% of total billed charges,28.7,70,,22.96,percent of total billed charges,70% of total billed charges,19.88,48.48,,15.904,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,19.88,48.48,,15.904,percent of total billed charges,48.48% of total billed charges,28.7,70,,22.96,percent of total billed charges,70% of total billed charges,28.7,70,,22.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,19.88,48.48,,15.904,percent of total billed charges,48.48% of total billed charges,36.9,90,,29.52,percent of total billed charges,90% of total billed charges,19.88,90,
NOC^ HUMAN PAPILLOMAVIRUS INJ,43601408,CDM,250,RC,90651,HCPCS,outpatient,1,UN,574,344.40,,344.4,60,,275.52,percent of total billed charges,60% of total billed charges,275.52,48,,220.416,percent of total billed charges,48% of total billed charges,259.7,100,,,fee schedule,100% of bcbs custom fee schedule,259.7,100,,,fee schedule,100% of bcbs custom fee schedule,288.27,111,,,fee schedule,111% of bcbs custom fee schedule,287,50,,229.6,percent of total billed charges,50% of total billed charges,401.8,70,,321.44,percent of total billed charges,70% of total billed charges,278.28,48.48,,222.624,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,278.28,48.48,,222.624,percent of total billed charges,48.48% of total billed charges,401.8,70,,321.44,percent of total billed charges,70% of total billed charges,401.8,70,,321.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,278.28,48.48,,222.624,percent of total billed charges,48.48% of total billed charges,516.6,90,,413.28,percent of total billed charges,90% of total billed charges,48.48,516.6,
NOC^ DILTIAZEM INJ [25 MG/5 ML,,,250,RC,J3490,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
HUMALOG INJ,,,636,RC,J1815,HCPCS,outpatient,,,16.5,9.90,,9.9,60,,7.92,percent of total billed charges,60% of total billed charges,7.92,48,,6.336,percent of total billed charges,48% of total billed charges,0.96,100,,,fee schedule,100% of bcbs custom fee schedule,0.96,100,,,fee schedule,100% of bcbs custom fee schedule,1.07,111,,,fee schedule,111% of bcbs custom fee schedule,8.25,50,,6.6,percent of total billed charges,50% of total billed charges,11.55,70,,9.24,percent of total billed charges,70% of total billed charges,8,48.48,,6.4,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,8,48.48,,6.4,percent of total billed charges,48.48% of total billed charges,11.55,70,,9.24,percent of total billed charges,70% of total billed charges,11.55,70,,9.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,8,48.48,,6.4,percent of total billed charges,48.48% of total billed charges,14.85,90,,11.88,percent of total billed charges,90% of total billed charges,8,90,
AMPICILLIN INJ [500 MG],,,636,RC,J0290,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,1.01,100,,,fee schedule,100% of bcbs custom fee schedule,1.01,100,,,fee schedule,100% of bcbs custom fee schedule,1.12,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
HEP B VACC 20MCG/ML,36000023,CDM,636,RC,90746,HCPCS,outpatient,1,UN,149,89.40,,89.4,60,,71.52,percent of total billed charges,60% of total billed charges,71.52,48,,57.216,percent of total billed charges,48% of total billed charges,76.62,100,,,fee schedule,100% of bcbs custom fee schedule,76.62,100,,,fee schedule,100% of bcbs custom fee schedule,85.05,111,,,fee schedule,111% of bcbs custom fee schedule,74.5,50,,59.6,percent of total billed charges,50% of total billed charges,104.3,70,,83.44,percent of total billed charges,70% of total billed charges,72.24,48.48,,57.792,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,72.24,48.48,,57.792,percent of total billed charges,48.48% of total billed charges,104.3,70,,83.44,percent of total billed charges,70% of total billed charges,104.3,70,,83.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,72.24,48.48,,57.792,percent of total billed charges,48.48% of total billed charges,134.1,90,,107.28,percent of total billed charges,90% of total billed charges,48.48,134.1,
DOPAMINE/ D5W PREMIX [400,,,636,RC,J1265,HCPCS,outpatient,1,UN,63,37.80,,37.8,60,,30.24,percent of total billed charges,60% of total billed charges,30.24,48,,24.192,percent of total billed charges,48% of total billed charges,0.62,100,,,fee schedule,100% of bcbs custom fee schedule,0.62,100,,,fee schedule,100% of bcbs custom fee schedule,0.69,111,,,fee schedule,111% of bcbs custom fee schedule,31.5,50,,25.2,percent of total billed charges,50% of total billed charges,44.1,70,,35.28,percent of total billed charges,70% of total billed charges,30.54,48.48,,24.432,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,30.54,48.48,,24.432,percent of total billed charges,48.48% of total billed charges,44.1,70,,35.28,percent of total billed charges,70% of total billed charges,44.1,70,,35.28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,30.54,48.48,,24.432,percent of total billed charges,48.48% of total billed charges,56.7,90,,45.36,percent of total billed charges,90% of total billed charges,30.54,90,
NOC^ VARENICLINE TAB [0.5 MG],,,259,RC,J3490,HCPCS,outpatient,1,UN,17,10.20,,10.2,60,,8.16,percent of total billed charges,60% of total billed charges,8.16,48,,6.528,percent of total billed charges,48% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,11.9,70,,9.52,percent of total billed charges,70% of total billed charges,8.24,48.48,,6.592,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,8.24,48.48,,6.592,percent of total billed charges,48.48% of total billed charges,11.9,70,,9.52,percent of total billed charges,70% of total billed charges,11.9,70,,9.52,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,8.24,48.48,,6.592,percent of total billed charges,48.48% of total billed charges,15.3,90,,12.24,percent of total billed charges,90% of total billed charges,8.24,90,
NOC^ ALENDRONATE TAB 10 MG,,,259,RC,J3490,HCPCS,outpatient,1,UN,12,7.20,,7.2,60,,5.76,percent of total billed charges,60% of total billed charges,5.76,48,,4.608,percent of total billed charges,48% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,8.4,70,,6.72,percent of total billed charges,70% of total billed charges,5.82,48.48,,4.656,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,5.82,48.48,,4.656,percent of total billed charges,48.48% of total billed charges,8.4,70,,6.72,percent of total billed charges,70% of total billed charges,8.4,70,,6.72,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,5.82,48.48,,4.656,percent of total billed charges,48.48% of total billed charges,10.8,90,,8.64,percent of total billed charges,90% of total billed charges,5.82,90,
NOC^ VARENICLINE TAB [1 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,40,24.00,,24,60,,19.2,percent of total billed charges,60% of total billed charges,19.2,48,,15.36,percent of total billed charges,48% of total billed charges,20,50,,16,percent of total billed charges,50% of total billed charges,20,50,,16,percent of total billed charges,50% of total billed charges,20,50,,16,percent of total billed charges,50% of total billed charges,20,50,,16,percent of total billed charges,50% of total billed charges,28,70,,22.4,percent of total billed charges,70% of total billed charges,19.39,48.48,,15.512,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,19.39,48.48,,15.512,percent of total billed charges,48.48% of total billed charges,28,70,,22.4,percent of total billed charges,70% of total billed charges,28,70,,22.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,19.39,48.48,,15.512,percent of total billed charges,48.48% of total billed charges,36,90,,28.8,percent of total billed charges,90% of total billed charges,19.39,90,
NOC^ COLESTIPOL TAB 1 GM,,,259,RC,J8499,HCPCS,outpatient,1,UN,11,6.60,,6.6,60,,5.28,percent of total billed charges,60% of total billed charges,5.28,48,,4.224,percent of total billed charges,48% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,9.9,90,,7.92,percent of total billed charges,90% of total billed charges,5.33,90,
NOC^ PRAVASTATIN TAB [20 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,14,8.40,,8.4,60,,6.72,percent of total billed charges,60% of total billed charges,6.72,48,,5.376,percent of total billed charges,48% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,9.8,70,,7.84,percent of total billed charges,70% of total billed charges,6.79,48.48,,5.432,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,6.79,48.48,,5.432,percent of total billed charges,48.48% of total billed charges,9.8,70,,7.84,percent of total billed charges,70% of total billed charges,9.8,70,,7.84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,6.79,48.48,,5.432,percent of total billed charges,48.48% of total billed charges,12.6,90,,10.08,percent of total billed charges,90% of total billed charges,6.79,90,
"HEPARIN INJ [5,000 UNT/ML",,,636,RC,J1644,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,0.32,100,,,fee schedule,100% of bcbs custom fee schedule,0.32,100,,,fee schedule,100% of bcbs custom fee schedule,0.36,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
MULTIVITAMIN INJ,,,250,RC,J3490,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
HALOPERIDOL DEC 100MG/ML,,,636,RC,,,outpatient,,,248,148.80,,148.8,60,,119.04,percent of total billed charges,60% of total billed charges,119.04,48,,95.232,percent of total billed charges,48% of total billed charges,124,50,,99.2,percent of total billed charges,50% of total billed charges,124,50,,99.2,percent of total billed charges,50% of total billed charges,124,50,,99.2,percent of total billed charges,50% of total billed charges,124,50,,99.2,percent of total billed charges,50% of total billed charges,173.6,70,,138.88,percent of total billed charges,70% of total billed charges,120.23,48.48,,96.184,percent of total billed charges,48.48% of total billed charges,120.23,48.48,,96.184,percent of total billed charges,48.48% of total billed charges,120.23,48.48,,96.184,percent of total billed charges,48.48% of total billed charges,173.6,70,,138.88,percent of total billed charges,70% of total billed charges,173.6,70,,138.88,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,120.23,48.48,,96.184,percent of total billed charges,48.48% of total billed charges,223.2,90,,178.56,percent of total billed charges,90% of total billed charges,48.48,223.2,
HALOPERIDOL INJ [5 MG/ML],,,250,RC,J1630,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,1,100,,,fee schedule,100% of bcbs custom fee schedule,1,100,,,fee schedule,100% of bcbs custom fee schedule,1.11,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
INS- REG HUMAN INJ [100 U,,,250,RC,J1815,HCPCS,outpatient,1,UN,24,14.40,,14.4,60,,11.52,percent of total billed charges,60% of total billed charges,11.52,48,,9.216,percent of total billed charges,48% of total billed charges,0.96,100,,,fee schedule,100% of bcbs custom fee schedule,0.96,100,,,fee schedule,100% of bcbs custom fee schedule,1.07,111,,,fee schedule,111% of bcbs custom fee schedule,12,50,,9.6,percent of total billed charges,50% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,21.6,90,,17.28,percent of total billed charges,90% of total billed charges,11.64,90,
HEPARIN FLUSH 100 UNT/ML,,,250,RC,J1644,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,0.32,100,,,fee schedule,100% of bcbs custom fee schedule,0.32,100,,,fee schedule,100% of bcbs custom fee schedule,0.36,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
NOC^ DOXYCYCLINE INJ [100 MG],,,250,RC,J3490,HCPCS,outpatient,1,UN,59,35.40,,35.4,60,,28.32,percent of total billed charges,60% of total billed charges,28.32,48,,22.656,percent of total billed charges,48% of total billed charges,29.5,50,,23.6,percent of total billed charges,50% of total billed charges,29.5,50,,23.6,percent of total billed charges,50% of total billed charges,29.5,50,,23.6,percent of total billed charges,50% of total billed charges,29.5,50,,23.6,percent of total billed charges,50% of total billed charges,41.3,70,,33.04,percent of total billed charges,70% of total billed charges,28.6,48.48,,22.88,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,28.6,48.48,,22.88,percent of total billed charges,48.48% of total billed charges,41.3,70,,33.04,percent of total billed charges,70% of total billed charges,41.3,70,,33.04,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,28.6,48.48,,22.88,percent of total billed charges,48.48% of total billed charges,53.1,90,,42.48,percent of total billed charges,90% of total billed charges,28.6,90,
NOC^ DOXYCYCLINE CAP 100 M,,,250,RC,J8499,HCPCS,outpatient,1,UN,22,13.20,,13.2,60,,10.56,percent of total billed charges,60% of total billed charges,10.56,48,,8.448,percent of total billed charges,48% of total billed charges,11,50,,8.8,percent of total billed charges,50% of total billed charges,11,50,,8.8,percent of total billed charges,50% of total billed charges,11,50,,8.8,percent of total billed charges,50% of total billed charges,11,50,,8.8,percent of total billed charges,50% of total billed charges,15.4,70,,12.32,percent of total billed charges,70% of total billed charges,10.67,48.48,,8.536,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,10.67,48.48,,8.536,percent of total billed charges,48.48% of total billed charges,15.4,70,,12.32,percent of total billed charges,70% of total billed charges,15.4,70,,12.32,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,10.67,48.48,,8.536,percent of total billed charges,48.48% of total billed charges,19.8,90,,15.84,percent of total billed charges,90% of total billed charges,10.67,90,
CIPROFLOXACIN 400 MG PREMIX,,,636,RC,J0744,HCPCS,outpatient,2,UN,35,21.00,,21,60,,16.8,percent of total billed charges,60% of total billed charges,16.8,48,,13.44,percent of total billed charges,48% of total billed charges,1.1,100,,,fee schedule,100% of bcbs custom fee schedule,1.1,100,,,fee schedule,100% of bcbs custom fee schedule,1.22,111,,,fee schedule,111% of bcbs custom fee schedule,17.5,50,,14,percent of total billed charges,50% of total billed charges,24.5,70,,19.6,percent of total billed charges,70% of total billed charges,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,24.5,70,,19.6,percent of total billed charges,70% of total billed charges,24.5,70,,19.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,31.5,90,,25.2,percent of total billed charges,90% of total billed charges,16.97,90,
NOC^ AMIODARONE TAB [200 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,14,8.40,,8.4,60,,6.72,percent of total billed charges,60% of total billed charges,6.72,48,,5.376,percent of total billed charges,48% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,9.8,70,,7.84,percent of total billed charges,70% of total billed charges,6.79,48.48,,5.432,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,6.79,48.48,,5.432,percent of total billed charges,48.48% of total billed charges,9.8,70,,7.84,percent of total billed charges,70% of total billed charges,9.8,70,,7.84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,6.79,48.48,,5.432,percent of total billed charges,48.48% of total billed charges,12.6,90,,10.08,percent of total billed charges,90% of total billed charges,6.79,90,
INS- NPH HUMAN INJ [100 U,,,250,RC,J1815,HCPCS,outpatient,1,UN,24,14.40,,14.4,60,,11.52,percent of total billed charges,60% of total billed charges,11.52,48,,9.216,percent of total billed charges,48% of total billed charges,0.96,100,,,fee schedule,100% of bcbs custom fee schedule,0.96,100,,,fee schedule,100% of bcbs custom fee schedule,1.07,111,,,fee schedule,111% of bcbs custom fee schedule,12,50,,9.6,percent of total billed charges,50% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,21.6,90,,17.28,percent of total billed charges,90% of total billed charges,11.64,90,
NOC^ HYDROCORTISONE 1% CRM,,,259,RC,J3490,HCPCS,outpatient,1,UN,14,8.40,,8.4,60,,6.72,percent of total billed charges,60% of total billed charges,6.72,48,,5.376,percent of total billed charges,48% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,9.8,70,,7.84,percent of total billed charges,70% of total billed charges,6.79,48.48,,5.432,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,6.79,48.48,,5.432,percent of total billed charges,48.48% of total billed charges,9.8,70,,7.84,percent of total billed charges,70% of total billed charges,9.8,70,,7.84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,6.79,48.48,,5.432,percent of total billed charges,48.48% of total billed charges,12.6,90,,10.08,percent of total billed charges,90% of total billed charges,6.79,90,
INS- NPH HUMAN/ REG HUMAN,,,250,RC,J1815,HCPCS,outpatient,1,UN,24,14.40,,14.4,60,,11.52,percent of total billed charges,60% of total billed charges,11.52,48,,9.216,percent of total billed charges,48% of total billed charges,0.96,100,,,fee schedule,100% of bcbs custom fee schedule,0.96,100,,,fee schedule,100% of bcbs custom fee schedule,1.07,111,,,fee schedule,111% of bcbs custom fee schedule,12,50,,9.6,percent of total billed charges,50% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,21.6,90,,17.28,percent of total billed charges,90% of total billed charges,11.64,90,
HEPARIN FLUSH SYR 100U/ML,,,250,RC,J1642,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,0.01,100,,,fee schedule,100% of bcbs custom fee schedule,0.01,100,,,fee schedule,100% of bcbs custom fee schedule,0.01,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
NOC^ ZIPRASIDONE CAP [20 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,44,26.40,,26.4,60,,21.12,percent of total billed charges,60% of total billed charges,21.12,48,,16.896,percent of total billed charges,48% of total billed charges,22,50,,17.6,percent of total billed charges,50% of total billed charges,22,50,,17.6,percent of total billed charges,50% of total billed charges,22,50,,17.6,percent of total billed charges,50% of total billed charges,22,50,,17.6,percent of total billed charges,50% of total billed charges,30.8,70,,24.64,percent of total billed charges,70% of total billed charges,21.33,48.48,,17.064,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,21.33,48.48,,17.064,percent of total billed charges,48.48% of total billed charges,30.8,70,,24.64,percent of total billed charges,70% of total billed charges,30.8,70,,24.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,21.33,48.48,,17.064,percent of total billed charges,48.48% of total billed charges,39.6,90,,31.68,percent of total billed charges,90% of total billed charges,21.33,90,
NOC^ FLUSH SOD CL 0.9% FLUSH,,,272,RC,A4216,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,0.45,100,,,fee schedule,100% of bcbs custom fee schedule,0.45,100,,,fee schedule,100% of bcbs custom fee schedule,0.5,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
BENGAY ULTRA STR CREAM,,,259,RC,J3490,HCPCS,outpatient,1,UN,23,13.80,,13.8,60,,11.04,percent of total billed charges,60% of total billed charges,11.04,48,,8.832,percent of total billed charges,48% of total billed charges,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,16.1,70,,12.88,percent of total billed charges,70% of total billed charges,11.15,48.48,,8.92,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,11.15,48.48,,8.92,percent of total billed charges,48.48% of total billed charges,16.1,70,,12.88,percent of total billed charges,70% of total billed charges,16.1,70,,12.88,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,11.15,48.48,,8.92,percent of total billed charges,48.48% of total billed charges,20.7,90,,16.56,percent of total billed charges,90% of total billed charges,11.15,90,
NOC^ FLUCONAZOLE TAB [150 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,56,33.60,,33.6,60,,26.88,percent of total billed charges,60% of total billed charges,26.88,48,,21.504,percent of total billed charges,48% of total billed charges,28,50,,22.4,percent of total billed charges,50% of total billed charges,28,50,,22.4,percent of total billed charges,50% of total billed charges,28,50,,22.4,percent of total billed charges,50% of total billed charges,28,50,,22.4,percent of total billed charges,50% of total billed charges,39.2,70,,31.36,percent of total billed charges,70% of total billed charges,27.15,48.48,,21.72,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,27.15,48.48,,21.72,percent of total billed charges,48.48% of total billed charges,39.2,70,,31.36,percent of total billed charges,70% of total billed charges,39.2,70,,31.36,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,27.15,48.48,,21.72,percent of total billed charges,48.48% of total billed charges,50.4,90,,40.32,percent of total billed charges,90% of total billed charges,27.15,90,
FLUCONAZOLE 400MG/200ML PRMX,,,636,RC,J1450,HCPCS,outpatient,1,UN,100,60.00,,60,60,,48,percent of total billed charges,60% of total billed charges,48,48,,38.4,percent of total billed charges,48% of total billed charges,3.77,100,,,fee schedule,100% of bcbs custom fee schedule,3.77,100,,,fee schedule,100% of bcbs custom fee schedule,4.18,111,,,fee schedule,111% of bcbs custom fee schedule,50,50,,40,percent of total billed charges,50% of total billed charges,70,70,,56,percent of total billed charges,70% of total billed charges,48.48,48.48,,38.784,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,48.48,48.48,,38.784,percent of total billed charges,48.48% of total billed charges,70,70,,56,percent of total billed charges,70% of total billed charges,70,70,,56,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,48.48,48.48,,38.784,percent of total billed charges,48.48% of total billed charges,90,90,,72,percent of total billed charges,90% of total billed charges,48.48,90,
NOC^ VENLAFAXINE XR CAP 150 MG,,,259,RC,J8499,HCPCS,outpatient,1,UN,31,18.60,,18.6,60,,14.88,percent of total billed charges,60% of total billed charges,14.88,48,,11.904,percent of total billed charges,48% of total billed charges,15.5,50,,12.4,percent of total billed charges,50% of total billed charges,15.5,50,,12.4,percent of total billed charges,50% of total billed charges,15.5,50,,12.4,percent of total billed charges,50% of total billed charges,15.5,50,,12.4,percent of total billed charges,50% of total billed charges,21.7,70,,17.36,percent of total billed charges,70% of total billed charges,15.03,48.48,,12.024,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,15.03,48.48,,12.024,percent of total billed charges,48.48% of total billed charges,21.7,70,,17.36,percent of total billed charges,70% of total billed charges,21.7,70,,17.36,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,15.03,48.48,,12.024,percent of total billed charges,48.48% of total billed charges,27.9,90,,22.32,percent of total billed charges,90% of total billed charges,15.03,90,
HEPARIN PREMIX 100 UNT/ML,,,636,RC,J1644,HCPCS,outpatient,1,UN,47,28.20,,28.2,60,,22.56,percent of total billed charges,60% of total billed charges,22.56,48,,18.048,percent of total billed charges,48% of total billed charges,0.32,100,,,fee schedule,100% of bcbs custom fee schedule,0.32,100,,,fee schedule,100% of bcbs custom fee schedule,0.36,111,,,fee schedule,111% of bcbs custom fee schedule,23.5,50,,18.8,percent of total billed charges,50% of total billed charges,32.9,70,,26.32,percent of total billed charges,70% of total billed charges,22.79,48.48,,18.232,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,22.79,48.48,,18.232,percent of total billed charges,48.48% of total billed charges,32.9,70,,26.32,percent of total billed charges,70% of total billed charges,32.9,70,,26.32,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,22.79,48.48,,18.232,percent of total billed charges,48.48% of total billed charges,42.3,90,,33.84,percent of total billed charges,90% of total billed charges,22.79,90,
HEPARIN PREMIX 50 UNT/ML,,,636,RC,J1644,HCPCS,outpatient,1,UN,33,19.80,,19.8,60,,15.84,percent of total billed charges,60% of total billed charges,15.84,48,,12.672,percent of total billed charges,48% of total billed charges,0.32,100,,,fee schedule,100% of bcbs custom fee schedule,0.32,100,,,fee schedule,100% of bcbs custom fee schedule,0.36,111,,,fee schedule,111% of bcbs custom fee schedule,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,23.1,70,,18.48,percent of total billed charges,70% of total billed charges,16,48.48,,12.8,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,16,48.48,,12.8,percent of total billed charges,48.48% of total billed charges,23.1,70,,18.48,percent of total billed charges,70% of total billed charges,23.1,70,,18.48,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,16,48.48,,12.8,percent of total billed charges,48.48% of total billed charges,29.7,90,,23.76,percent of total billed charges,90% of total billed charges,16,90,
PROPRANOLOL INJ 1MG/ML,,,636,RC,J1800,HCPCS,outpatient,1,UN,49,29.40,,29.4,60,,23.52,percent of total billed charges,60% of total billed charges,23.52,48,,18.816,percent of total billed charges,48% of total billed charges,4.39,100,,,fee schedule,100% of bcbs custom fee schedule,4.39,100,,,fee schedule,100% of bcbs custom fee schedule,4.87,111,,,fee schedule,111% of bcbs custom fee schedule,24.5,50,,19.6,percent of total billed charges,50% of total billed charges,34.3,70,,27.44,percent of total billed charges,70% of total billed charges,23.76,48.48,,19.008,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,23.76,48.48,,19.008,percent of total billed charges,48.48% of total billed charges,34.3,70,,27.44,percent of total billed charges,70% of total billed charges,34.3,70,,27.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,23.76,48.48,,19.008,percent of total billed charges,48.48% of total billed charges,44.1,90,,35.28,percent of total billed charges,90% of total billed charges,23.76,90,
CEFPROZIL TAB [250 MG],,,259,RC,S5000,HCPCS,outpatient,1,UN,18,10.80,,10.8,60,,8.64,percent of total billed charges,60% of total billed charges,8.64,48,,6.912,percent of total billed charges,48% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,12.6,70,,10.08,percent of total billed charges,70% of total billed charges,8.73,48.48,,6.984,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,8.73,48.48,,6.984,percent of total billed charges,48.48% of total billed charges,12.6,70,,10.08,percent of total billed charges,70% of total billed charges,12.6,70,,10.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,8.73,48.48,,6.984,percent of total billed charges,48.48% of total billed charges,16.2,90,,12.96,percent of total billed charges,90% of total billed charges,8.73,90,
NOC^ AMOXICIL/ POT CLAV TAB [8,,,259,RC,J3490,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
ACULAR LS OPTH 5ML,,,259,RC,,,outpatient,,,195,117.00,,117,60,,93.6,percent of total billed charges,60% of total billed charges,93.6,48,,74.88,percent of total billed charges,48% of total billed charges,97.5,50,,78,percent of total billed charges,50% of total billed charges,97.5,50,,78,percent of total billed charges,50% of total billed charges,97.5,50,,78,percent of total billed charges,50% of total billed charges,97.5,50,,78,percent of total billed charges,50% of total billed charges,136.5,70,,109.2,percent of total billed charges,70% of total billed charges,94.54,48.48,,75.632,percent of total billed charges,48.48% of total billed charges,94.54,48.48,,75.632,percent of total billed charges,48.48% of total billed charges,94.54,48.48,,75.632,percent of total billed charges,48.48% of total billed charges,136.5,70,,109.2,percent of total billed charges,70% of total billed charges,136.5,70,,109.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,94.54,48.48,,75.632,percent of total billed charges,48.48% of total billed charges,175.5,90,,140.4,percent of total billed charges,90% of total billed charges,48.48,175.5,
NOC^ KETOROLAC DRP 0.5%,,,259,RC,J3490,HCPCS,outpatient,1,UN,490,294.00,,294,60,,235.2,percent of total billed charges,60% of total billed charges,235.2,48,,188.16,percent of total billed charges,48% of total billed charges,245,50,,196,percent of total billed charges,50% of total billed charges,245,50,,196,percent of total billed charges,50% of total billed charges,245,50,,196,percent of total billed charges,50% of total billed charges,245,50,,196,percent of total billed charges,50% of total billed charges,343,70,,274.4,percent of total billed charges,70% of total billed charges,237.55,48.48,,190.04,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,237.55,48.48,,190.04,percent of total billed charges,48.48% of total billed charges,343,70,,274.4,percent of total billed charges,70% of total billed charges,343,70,,274.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,237.55,48.48,,190.04,percent of total billed charges,48.48% of total billed charges,441,90,,352.8,percent of total billed charges,90% of total billed charges,48.48,441,
NOC^ ECONAZOLE 1% CRM,,,259,RC,J3490,HCPCS,outpatient,1,UN,870,522.00,,522,60,,417.6,percent of total billed charges,60% of total billed charges,417.6,48,,334.08,percent of total billed charges,48% of total billed charges,435,50,,348,percent of total billed charges,50% of total billed charges,435,50,,348,percent of total billed charges,50% of total billed charges,435,50,,348,percent of total billed charges,50% of total billed charges,435,50,,348,percent of total billed charges,50% of total billed charges,609,70,,487.2,percent of total billed charges,70% of total billed charges,421.78,48.48,,337.424,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,421.78,48.48,,337.424,percent of total billed charges,48.48% of total billed charges,609,70,,487.2,percent of total billed charges,70% of total billed charges,609,70,,487.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,421.78,48.48,,337.424,percent of total billed charges,48.48% of total billed charges,783,90,,626.4,percent of total billed charges,90% of total billed charges,48.48,783,
NOC^ DORZOLMD/ TIMLOL DRP,,,259,RC,J3490,HCPCS,outpatient,1,UN,491,294.60,,294.6,60,,235.68,percent of total billed charges,60% of total billed charges,235.68,48,,188.544,percent of total billed charges,48% of total billed charges,245.5,50,,196.4,percent of total billed charges,50% of total billed charges,245.5,50,,196.4,percent of total billed charges,50% of total billed charges,245.5,50,,196.4,percent of total billed charges,50% of total billed charges,245.5,50,,196.4,percent of total billed charges,50% of total billed charges,343.7,70,,274.96,percent of total billed charges,70% of total billed charges,238.04,48.48,,190.432,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,238.04,48.48,,190.432,percent of total billed charges,48.48% of total billed charges,343.7,70,,274.96,percent of total billed charges,70% of total billed charges,343.7,70,,274.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,238.04,48.48,,190.432,percent of total billed charges,48.48% of total billed charges,441.9,90,,353.52,percent of total billed charges,90% of total billed charges,48.48,441.9,
ESTRADIOL 0.01% CRM,,,259,RC,J3490,HCPCS,outpatient,1,UN,600,360.00,,360,60,,288,percent of total billed charges,60% of total billed charges,288,48,,230.4,percent of total billed charges,48% of total billed charges,300,50,,240,percent of total billed charges,50% of total billed charges,300,50,,240,percent of total billed charges,50% of total billed charges,300,50,,240,percent of total billed charges,50% of total billed charges,300,50,,240,percent of total billed charges,50% of total billed charges,420,70,,336,percent of total billed charges,70% of total billed charges,290.88,48.48,,232.704,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,290.88,48.48,,232.704,percent of total billed charges,48.48% of total billed charges,420,70,,336,percent of total billed charges,70% of total billed charges,420,70,,336,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,290.88,48.48,,232.704,percent of total billed charges,48.48% of total billed charges,540,90,,432,percent of total billed charges,90% of total billed charges,48.48,540,
GENTAMICIN INJ [40MG/ML],43601682,CDM,250,RC,J1580,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,1.97,100,,,fee schedule,100% of bcbs custom fee schedule,1.97,100,,,fee schedule,100% of bcbs custom fee schedule,2.19,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
NOC^ SUCRALFATE SUS [1 GM/10ML,,,259,RC,J3490,HCPCS,outpatient,1,UN,49,29.40,,29.4,60,,23.52,percent of total billed charges,60% of total billed charges,23.52,48,,18.816,percent of total billed charges,48% of total billed charges,24.5,50,,19.6,percent of total billed charges,50% of total billed charges,24.5,50,,19.6,percent of total billed charges,50% of total billed charges,24.5,50,,19.6,percent of total billed charges,50% of total billed charges,24.5,50,,19.6,percent of total billed charges,50% of total billed charges,34.3,70,,27.44,percent of total billed charges,70% of total billed charges,23.76,48.48,,19.008,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,23.76,48.48,,19.008,percent of total billed charges,48.48% of total billed charges,34.3,70,,27.44,percent of total billed charges,70% of total billed charges,34.3,70,,27.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,23.76,48.48,,19.008,percent of total billed charges,48.48% of total billed charges,44.1,90,,35.28,percent of total billed charges,90% of total billed charges,23.76,90,
ADENOSINE SRYG 6 MG,,,636,RC,J0153,HCPCS,outpatient,6,UN,77,46.20,,46.2,60,,36.96,percent of total billed charges,60% of total billed charges,36.96,48,,29.568,percent of total billed charges,48% of total billed charges,0.63,100,,,fee schedule,100% of bcbs custom fee schedule,0.63,100,,,fee schedule,100% of bcbs custom fee schedule,0.7,111,,,fee schedule,111% of bcbs custom fee schedule,38.5,50,,30.8,percent of total billed charges,50% of total billed charges,53.9,70,,43.12,percent of total billed charges,70% of total billed charges,37.33,48.48,,29.864,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,37.33,48.48,,29.864,percent of total billed charges,48.48% of total billed charges,53.9,70,,43.12,percent of total billed charges,70% of total billed charges,53.9,70,,43.12,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,37.33,48.48,,29.864,percent of total billed charges,48.48% of total billed charges,69.3,90,,55.44,percent of total billed charges,90% of total billed charges,37.33,90,
NOC^ ROSUVASTATIN TAB [10 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,26,15.60,,15.6,60,,12.48,percent of total billed charges,60% of total billed charges,12.48,48,,9.984,percent of total billed charges,48% of total billed charges,13,50,,10.4,percent of total billed charges,50% of total billed charges,13,50,,10.4,percent of total billed charges,50% of total billed charges,13,50,,10.4,percent of total billed charges,50% of total billed charges,13,50,,10.4,percent of total billed charges,50% of total billed charges,18.2,70,,14.56,percent of total billed charges,70% of total billed charges,12.6,48.48,,10.08,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,12.6,48.48,,10.08,percent of total billed charges,48.48% of total billed charges,18.2,70,,14.56,percent of total billed charges,70% of total billed charges,18.2,70,,14.56,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,12.6,48.48,,10.08,percent of total billed charges,48.48% of total billed charges,23.4,90,,18.72,percent of total billed charges,90% of total billed charges,12.6,90,
CIPROFLOXACIN 200 MG PREMIX,,,636,RC,J0744,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,1.1,100,,,fee schedule,100% of bcbs custom fee schedule,1.1,100,,,fee schedule,100% of bcbs custom fee schedule,1.22,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
NOC^ VALSARTAN/HCTZ 160-12.5 M,,,259,RC,J8499,HCPCS,outpatient,1,UN,19,11.40,,11.4,60,,9.12,percent of total billed charges,60% of total billed charges,9.12,48,,7.296,percent of total billed charges,48% of total billed charges,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,13.3,70,,10.64,percent of total billed charges,70% of total billed charges,9.21,48.48,,7.368,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.21,48.48,,7.368,percent of total billed charges,48.48% of total billed charges,13.3,70,,10.64,percent of total billed charges,70% of total billed charges,13.3,70,,10.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.21,48.48,,7.368,percent of total billed charges,48.48% of total billed charges,17.1,90,,13.68,percent of total billed charges,90% of total billed charges,9.21,90,
NOC^ MISOPROSTOL TAB [100 MCG],,,259,RC,J3490,HCPCS,outpatient,1,UN,10,6.00,,6,60,,4.8,percent of total billed charges,60% of total billed charges,4.8,48,,3.84,percent of total billed charges,48% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,7,70,,5.6,percent of total billed charges,70% of total billed charges,4.85,48.48,,3.88,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,4.85,48.48,,3.88,percent of total billed charges,48.48% of total billed charges,7,70,,5.6,percent of total billed charges,70% of total billed charges,7,70,,5.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,4.85,48.48,,3.88,percent of total billed charges,48.48% of total billed charges,9,90,,7.2,percent of total billed charges,90% of total billed charges,4.85,90,
NOC^ DULOXETINE CAP [60MG],,,259,RC,J3490,HCPCS,outpatient,1,UN,32,19.20,,19.2,60,,15.36,percent of total billed charges,60% of total billed charges,15.36,48,,12.288,percent of total billed charges,48% of total billed charges,16,50,,12.8,percent of total billed charges,50% of total billed charges,16,50,,12.8,percent of total billed charges,50% of total billed charges,16,50,,12.8,percent of total billed charges,50% of total billed charges,16,50,,12.8,percent of total billed charges,50% of total billed charges,22.4,70,,17.92,percent of total billed charges,70% of total billed charges,15.51,48.48,,12.408,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,15.51,48.48,,12.408,percent of total billed charges,48.48% of total billed charges,22.4,70,,17.92,percent of total billed charges,70% of total billed charges,22.4,70,,17.92,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,15.51,48.48,,12.408,percent of total billed charges,48.48% of total billed charges,28.8,90,,23.04,percent of total billed charges,90% of total billed charges,15.51,90,
NOC^ DULOXETINE CAP [30MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,31,18.60,,18.6,60,,14.88,percent of total billed charges,60% of total billed charges,14.88,48,,11.904,percent of total billed charges,48% of total billed charges,15.5,50,,12.4,percent of total billed charges,50% of total billed charges,15.5,50,,12.4,percent of total billed charges,50% of total billed charges,15.5,50,,12.4,percent of total billed charges,50% of total billed charges,15.5,50,,12.4,percent of total billed charges,50% of total billed charges,21.7,70,,17.36,percent of total billed charges,70% of total billed charges,15.03,48.48,,12.024,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,15.03,48.48,,12.024,percent of total billed charges,48.48% of total billed charges,21.7,70,,17.36,percent of total billed charges,70% of total billed charges,21.7,70,,17.36,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,15.03,48.48,,12.024,percent of total billed charges,48.48% of total billed charges,27.9,90,,22.32,percent of total billed charges,90% of total billed charges,15.03,90,
NOC^ FLUTICASONE NAS SPR,,,259,RC,J3490,HCPCS,outpatient,1,UN,342,205.20,,205.2,60,,164.16,percent of total billed charges,60% of total billed charges,164.16,48,,131.328,percent of total billed charges,48% of total billed charges,171,50,,136.8,percent of total billed charges,50% of total billed charges,171,50,,136.8,percent of total billed charges,50% of total billed charges,171,50,,136.8,percent of total billed charges,50% of total billed charges,171,50,,136.8,percent of total billed charges,50% of total billed charges,239.4,70,,191.52,percent of total billed charges,70% of total billed charges,165.8,48.48,,132.64,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,165.8,48.48,,132.64,percent of total billed charges,48.48% of total billed charges,239.4,70,,191.52,percent of total billed charges,70% of total billed charges,239.4,70,,191.52,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,165.8,48.48,,132.64,percent of total billed charges,48.48% of total billed charges,307.8,90,,246.24,percent of total billed charges,90% of total billed charges,48.48,307.8,
NOC^ LOSARTAN/ HCTZ TB 50-12.5,,,259,RC,J3490,HCPCS,outpatient,1,UN,13,7.80,,7.8,60,,6.24,percent of total billed charges,60% of total billed charges,6.24,48,,4.992,percent of total billed charges,48% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,9.1,70,,7.28,percent of total billed charges,70% of total billed charges,6.3,48.48,,5.04,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,6.3,48.48,,5.04,percent of total billed charges,48.48% of total billed charges,9.1,70,,7.28,percent of total billed charges,70% of total billed charges,9.1,70,,7.28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,6.3,48.48,,5.04,percent of total billed charges,48.48% of total billed charges,11.7,90,,9.36,percent of total billed charges,90% of total billed charges,6.3,90,
NOC^ CEPHALEXIN SUS [250 MG/5M,,,259,RC,J3490,HCPCS,outpatient,1,UN,115,69.00,,69,60,,55.2,percent of total billed charges,60% of total billed charges,55.2,48,,44.16,percent of total billed charges,48% of total billed charges,57.5,50,,46,percent of total billed charges,50% of total billed charges,57.5,50,,46,percent of total billed charges,50% of total billed charges,57.5,50,,46,percent of total billed charges,50% of total billed charges,57.5,50,,46,percent of total billed charges,50% of total billed charges,80.5,70,,64.4,percent of total billed charges,70% of total billed charges,55.75,48.48,,44.6,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,55.75,48.48,,44.6,percent of total billed charges,48.48% of total billed charges,80.5,70,,64.4,percent of total billed charges,70% of total billed charges,80.5,70,,64.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,55.75,48.48,,44.6,percent of total billed charges,48.48% of total billed charges,103.5,90,,82.8,percent of total billed charges,90% of total billed charges,48.48,103.5,
NOC^ LEVETIRACETAM TAB [250 MG,,,259,RC,J8499,HCPCS,outpatient,1,UN,11,6.60,,6.6,60,,5.28,percent of total billed charges,60% of total billed charges,5.28,48,,4.224,percent of total billed charges,48% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,9.9,90,,7.92,percent of total billed charges,90% of total billed charges,5.33,90,
NOC^ ANASTROZOLE TAB [1 MG],,,259,RC,J3490,HCPCS,outpatient,1,UN,54,32.40,,32.4,60,,25.92,percent of total billed charges,60% of total billed charges,25.92,48,,20.736,percent of total billed charges,48% of total billed charges,27,50,,21.6,percent of total billed charges,50% of total billed charges,27,50,,21.6,percent of total billed charges,50% of total billed charges,27,50,,21.6,percent of total billed charges,50% of total billed charges,27,50,,21.6,percent of total billed charges,50% of total billed charges,37.8,70,,30.24,percent of total billed charges,70% of total billed charges,26.18,48.48,,20.944,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,26.18,48.48,,20.944,percent of total billed charges,48.48% of total billed charges,37.8,70,,30.24,percent of total billed charges,70% of total billed charges,37.8,70,,30.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,26.18,48.48,,20.944,percent of total billed charges,48.48% of total billed charges,48.6,90,,38.88,percent of total billed charges,90% of total billed charges,26.18,90,
SUMATRIPTAN INJ [6 MG/0.5,43601524,CDM,636,RC,J3030,HCPCS,outpatient,1,UN,340,204.00,,204,60,,163.2,percent of total billed charges,60% of total billed charges,163.2,48,,130.56,percent of total billed charges,48% of total billed charges,86.3,100,,,fee schedule,100% of bcbs custom fee schedule,86.3,100,,,fee schedule,100% of bcbs custom fee schedule,95.79,111,,,fee schedule,111% of bcbs custom fee schedule,170,50,,136,percent of total billed charges,50% of total billed charges,238,70,,190.4,percent of total billed charges,70% of total billed charges,164.83,48.48,,131.864,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,164.83,48.48,,131.864,percent of total billed charges,48.48% of total billed charges,238,70,,190.4,percent of total billed charges,70% of total billed charges,238,70,,190.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,164.83,48.48,,131.864,percent of total billed charges,48.48% of total billed charges,306,90,,244.8,percent of total billed charges,90% of total billed charges,48.48,306,
AMPICILLIN INJ 2 GM,,,636,RC,J0290,HCPCS,outpatient,1,UN,64,38.40,,38.4,60,,30.72,percent of total billed charges,60% of total billed charges,30.72,48,,24.576,percent of total billed charges,48% of total billed charges,1.01,100,,,fee schedule,100% of bcbs custom fee schedule,1.01,100,,,fee schedule,100% of bcbs custom fee schedule,1.12,111,,,fee schedule,111% of bcbs custom fee schedule,32,50,,25.6,percent of total billed charges,50% of total billed charges,44.8,70,,35.84,percent of total billed charges,70% of total billed charges,31.03,48.48,,24.824,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,31.03,48.48,,24.824,percent of total billed charges,48.48% of total billed charges,44.8,70,,35.84,percent of total billed charges,70% of total billed charges,44.8,70,,35.84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,31.03,48.48,,24.824,percent of total billed charges,48.48% of total billed charges,57.6,90,,46.08,percent of total billed charges,90% of total billed charges,31.03,90,
NOC^ SITAGLIPTIN TAB [100 MG],,,259,RC,J3490,HCPCS,outpatient,1,UN,40,24.00,,24,60,,19.2,percent of total billed charges,60% of total billed charges,19.2,48,,15.36,percent of total billed charges,48% of total billed charges,20,50,,16,percent of total billed charges,50% of total billed charges,20,50,,16,percent of total billed charges,50% of total billed charges,20,50,,16,percent of total billed charges,50% of total billed charges,20,50,,16,percent of total billed charges,50% of total billed charges,28,70,,22.4,percent of total billed charges,70% of total billed charges,19.39,48.48,,15.512,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,19.39,48.48,,15.512,percent of total billed charges,48.48% of total billed charges,28,70,,22.4,percent of total billed charges,70% of total billed charges,28,70,,22.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,19.39,48.48,,15.512,percent of total billed charges,48.48% of total billed charges,36,90,,28.8,percent of total billed charges,90% of total billed charges,19.39,90,
ISOPTO ATROPINE 1% 5ML,,,259,RC,,,outpatient,,,179,107.40,,107.4,60,,85.92,percent of total billed charges,60% of total billed charges,85.92,48,,68.736,percent of total billed charges,48% of total billed charges,89.5,50,,71.6,percent of total billed charges,50% of total billed charges,89.5,50,,71.6,percent of total billed charges,50% of total billed charges,89.5,50,,71.6,percent of total billed charges,50% of total billed charges,89.5,50,,71.6,percent of total billed charges,50% of total billed charges,125.3,70,,100.24,percent of total billed charges,70% of total billed charges,86.78,48.48,,69.424,percent of total billed charges,48.48% of total billed charges,86.78,48.48,,69.424,percent of total billed charges,48.48% of total billed charges,86.78,48.48,,69.424,percent of total billed charges,48.48% of total billed charges,125.3,70,,100.24,percent of total billed charges,70% of total billed charges,125.3,70,,100.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,86.78,48.48,,69.424,percent of total billed charges,48.48% of total billed charges,161.1,90,,128.88,percent of total billed charges,90% of total billed charges,48.48,161.1,
ARGININE/GLUTAMINE/CALC,,,257,RC,A9150,HCPCS,outpatient,1,UN,10,6.00,,6,60,,4.8,percent of total billed charges,60% of total billed charges,4.8,48,,3.84,percent of total billed charges,48% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,7,70,,5.6,percent of total billed charges,70% of total billed charges,4.85,48.48,,3.88,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,4.85,48.48,,3.88,percent of total billed charges,48.48% of total billed charges,7,70,,5.6,percent of total billed charges,70% of total billed charges,7,70,,5.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,4.85,48.48,,3.88,percent of total billed charges,48.48% of total billed charges,9,90,,7.2,percent of total billed charges,90% of total billed charges,4.85,90,
NOC^ FLUTICASONE MDI  [44 MCG],,,250,RC,J3490,HCPCS,outpatient,1,UN,1080,648.00,,648,60,,518.4,percent of total billed charges,60% of total billed charges,518.4,48,,414.72,percent of total billed charges,48% of total billed charges,540,50,,432,percent of total billed charges,50% of total billed charges,540,50,,432,percent of total billed charges,50% of total billed charges,540,50,,432,percent of total billed charges,50% of total billed charges,540,50,,432,percent of total billed charges,50% of total billed charges,756,70,,604.8,percent of total billed charges,70% of total billed charges,523.58,48.48,,418.864,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,523.58,48.48,,418.864,percent of total billed charges,48.48% of total billed charges,756,70,,604.8,percent of total billed charges,70% of total billed charges,756,70,,604.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,523.58,48.48,,418.864,percent of total billed charges,48.48% of total billed charges,972,90,,777.6,percent of total billed charges,90% of total billed charges,48.48,972,
NOC^ PEGS ELECTROLYTE SOL/golytely,,,259,RC,J3490,HCPCS,outpatient,1,UN,141,84.60,,84.6,60,,67.68,percent of total billed charges,60% of total billed charges,67.68,48,,54.144,percent of total billed charges,48% of total billed charges,70.5,50,,56.4,percent of total billed charges,50% of total billed charges,70.5,50,,56.4,percent of total billed charges,50% of total billed charges,70.5,50,,56.4,percent of total billed charges,50% of total billed charges,70.5,50,,56.4,percent of total billed charges,50% of total billed charges,98.7,70,,78.96,percent of total billed charges,70% of total billed charges,68.36,48.48,,54.688,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,68.36,48.48,,54.688,percent of total billed charges,48.48% of total billed charges,98.7,70,,78.96,percent of total billed charges,70% of total billed charges,98.7,70,,78.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,68.36,48.48,,54.688,percent of total billed charges,48.48% of total billed charges,126.9,90,,101.52,percent of total billed charges,90% of total billed charges,48.48,126.9,
AZELASTINE SPRY,,,259,RC,J3490,HCPCS,outpatient,1,UN,557,334.20,,334.2,60,,267.36,percent of total billed charges,60% of total billed charges,267.36,48,,213.888,percent of total billed charges,48% of total billed charges,278.5,50,,222.8,percent of total billed charges,50% of total billed charges,278.5,50,,222.8,percent of total billed charges,50% of total billed charges,278.5,50,,222.8,percent of total billed charges,50% of total billed charges,278.5,50,,222.8,percent of total billed charges,50% of total billed charges,389.9,70,,311.92,percent of total billed charges,70% of total billed charges,270.03,48.48,,216.024,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,270.03,48.48,,216.024,percent of total billed charges,48.48% of total billed charges,389.9,70,,311.92,percent of total billed charges,70% of total billed charges,389.9,70,,311.92,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,270.03,48.48,,216.024,percent of total billed charges,48.48% of total billed charges,501.3,90,,401.04,percent of total billed charges,90% of total billed charges,48.48,501.3,
EPINEPHRINE INJ [1MG/ML],43601500,CDM,636,RC,J0171,HCPCS,outpatient,1,UN,70,42.00,,42,60,,33.6,percent of total billed charges,60% of total billed charges,33.6,48,,26.88,percent of total billed charges,48% of total billed charges,0.97,100,,,fee schedule,100% of bcbs custom fee schedule,0.97,100,,,fee schedule,100% of bcbs custom fee schedule,1.08,111,,,fee schedule,111% of bcbs custom fee schedule,35,50,,28,percent of total billed charges,50% of total billed charges,49,70,,39.2,percent of total billed charges,70% of total billed charges,33.94,48.48,,27.152,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,33.94,48.48,,27.152,percent of total billed charges,48.48% of total billed charges,49,70,,39.2,percent of total billed charges,70% of total billed charges,49,70,,39.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,33.94,48.48,,27.152,percent of total billed charges,48.48% of total billed charges,63,90,,50.4,percent of total billed charges,90% of total billed charges,33.94,90,
NOC^ FOLIC ACID INJ [5 MG/ML],,,250,RC,J3490,HCPCS,outpatient,1,UN,24,14.40,,14.4,60,,11.52,percent of total billed charges,60% of total billed charges,11.52,48,,9.216,percent of total billed charges,48% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,21.6,90,,17.28,percent of total billed charges,90% of total billed charges,11.64,90,
NOC^ PRAMOXINE/ CHLOR/ HC DRP,,,259,RC,J3490,HCPCS,outpatient,1,UN,134,80.40,,80.4,60,,64.32,percent of total billed charges,60% of total billed charges,64.32,48,,51.456,percent of total billed charges,48% of total billed charges,67,50,,53.6,percent of total billed charges,50% of total billed charges,67,50,,53.6,percent of total billed charges,50% of total billed charges,67,50,,53.6,percent of total billed charges,50% of total billed charges,67,50,,53.6,percent of total billed charges,50% of total billed charges,93.8,70,,75.04,percent of total billed charges,70% of total billed charges,64.96,48.48,,51.968,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,64.96,48.48,,51.968,percent of total billed charges,48.48% of total billed charges,93.8,70,,75.04,percent of total billed charges,70% of total billed charges,93.8,70,,75.04,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,64.96,48.48,,51.968,percent of total billed charges,48.48% of total billed charges,120.6,90,,96.48,percent of total billed charges,90% of total billed charges,48.48,120.6,
NOC^ CARVEDILOL CR CAP [20 MG],,,259,RC,J3490,HCPCS,outpatient,1,UN,24,14.40,,14.4,60,,11.52,percent of total billed charges,60% of total billed charges,11.52,48,,9.216,percent of total billed charges,48% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,21.6,90,,17.28,percent of total billed charges,90% of total billed charges,11.64,90,
NOC^ LOPERAMIDE LIQ 2MG/10ML,,,257,RC,J3490,HCPCS,outpatient,1,UN,23,13.80,,13.8,60,,11.04,percent of total billed charges,60% of total billed charges,11.04,48,,8.832,percent of total billed charges,48% of total billed charges,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,16.1,70,,12.88,percent of total billed charges,70% of total billed charges,11.15,48.48,,8.92,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,11.15,48.48,,8.92,percent of total billed charges,48.48% of total billed charges,16.1,70,,12.88,percent of total billed charges,70% of total billed charges,16.1,70,,12.88,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,11.15,48.48,,8.92,percent of total billed charges,48.48% of total billed charges,20.7,90,,16.56,percent of total billed charges,90% of total billed charges,11.15,90,
IOPIDINE OPTH SOL .5% 5ML,,,259,RC,,,outpatient,,,348,208.80,,208.8,60,,167.04,percent of total billed charges,60% of total billed charges,167.04,48,,133.632,percent of total billed charges,48% of total billed charges,174,50,,139.2,percent of total billed charges,50% of total billed charges,174,50,,139.2,percent of total billed charges,50% of total billed charges,174,50,,139.2,percent of total billed charges,50% of total billed charges,174,50,,139.2,percent of total billed charges,50% of total billed charges,243.6,70,,194.88,percent of total billed charges,70% of total billed charges,168.71,48.48,,134.968,percent of total billed charges,48.48% of total billed charges,168.71,48.48,,134.968,percent of total billed charges,48.48% of total billed charges,168.71,48.48,,134.968,percent of total billed charges,48.48% of total billed charges,243.6,70,,194.88,percent of total billed charges,70% of total billed charges,243.6,70,,194.88,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,168.71,48.48,,134.968,percent of total billed charges,48.48% of total billed charges,313.2,90,,250.56,percent of total billed charges,90% of total billed charges,48.48,313.2,
NOC^ CLEOCIN PREMX [300MG/50ML,,,636,RC,J0736,HCPCS,outpatient,1,UN,40,24.00,,24,60,,19.2,percent of total billed charges,60% of total billed charges,19.2,48,,15.36,percent of total billed charges,48% of total billed charges,20,50,,16,percent of total billed charges,50% of total billed charges,20,50,,16,percent of total billed charges,50% of total billed charges,20,50,,16,percent of total billed charges,50% of total billed charges,20,50,,16,percent of total billed charges,50% of total billed charges,28,70,,22.4,percent of total billed charges,70% of total billed charges,19.39,48.48,,15.512,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,19.39,48.48,,15.512,percent of total billed charges,48.48% of total billed charges,28,70,,22.4,percent of total billed charges,70% of total billed charges,28,70,,22.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,19.39,48.48,,15.512,percent of total billed charges,48.48% of total billed charges,36,90,,28.8,percent of total billed charges,90% of total billed charges,19.39,90,
NOC^ CETAPHIL LOTION,,,257,RC,J3490,HCPCS,outpatient,1,UN,26,15.60,,15.6,60,,12.48,percent of total billed charges,60% of total billed charges,12.48,48,,9.984,percent of total billed charges,48% of total billed charges,13,50,,10.4,percent of total billed charges,50% of total billed charges,13,50,,10.4,percent of total billed charges,50% of total billed charges,13,50,,10.4,percent of total billed charges,50% of total billed charges,13,50,,10.4,percent of total billed charges,50% of total billed charges,18.2,70,,14.56,percent of total billed charges,70% of total billed charges,12.6,48.48,,10.08,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,12.6,48.48,,10.08,percent of total billed charges,48.48% of total billed charges,18.2,70,,14.56,percent of total billed charges,70% of total billed charges,18.2,70,,14.56,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,12.6,48.48,,10.08,percent of total billed charges,48.48% of total billed charges,23.4,90,,18.72,percent of total billed charges,90% of total billed charges,12.6,90,
NOC^ FLUTICASONE MDI (110 MCG),,,250,RC,J3490,HCPCS,outpatient,1,UN,1277,766.20,,766.2,60,,612.96,percent of total billed charges,60% of total billed charges,612.96,48,,490.368,percent of total billed charges,48% of total billed charges,638.5,50,,510.8,percent of total billed charges,50% of total billed charges,638.5,50,,510.8,percent of total billed charges,50% of total billed charges,638.5,50,,510.8,percent of total billed charges,50% of total billed charges,638.5,50,,510.8,percent of total billed charges,50% of total billed charges,893.9,70,,715.12,percent of total billed charges,70% of total billed charges,619.09,48.48,,495.272,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,619.09,48.48,,495.272,percent of total billed charges,48.48% of total billed charges,893.9,70,,715.12,percent of total billed charges,70% of total billed charges,893.9,70,,715.12,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,619.09,48.48,,495.272,percent of total billed charges,48.48% of total billed charges,1149.3,90,,919.44,percent of total billed charges,90% of total billed charges,48.48,1149.3,
NOC^ FLUTICASONE MDI [220 MCG],,,250,RC,J3490,HCPCS,outpatient,1,UN,1983,1189.80,,1189.8,60,,951.84,percent of total billed charges,60% of total billed charges,951.84,48,,761.472,percent of total billed charges,48% of total billed charges,991.5,50,,793.2,percent of total billed charges,50% of total billed charges,991.5,50,,793.2,percent of total billed charges,50% of total billed charges,991.5,50,,793.2,percent of total billed charges,50% of total billed charges,991.5,50,,793.2,percent of total billed charges,50% of total billed charges,1388.1,70,,1110.48,percent of total billed charges,70% of total billed charges,961.36,48.48,,769.088,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,961.36,48.48,,769.088,percent of total billed charges,48.48% of total billed charges,1388.1,70,,1110.48,percent of total billed charges,70% of total billed charges,1388.1,70,,1110.48,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,961.36,48.48,,769.088,percent of total billed charges,48.48% of total billed charges,1784.7,90,,1427.76,percent of total billed charges,90% of total billed charges,48.48,1784.7,
NOC^ CILOSTAZOL TAB [100 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,13,7.80,,7.8,60,,6.24,percent of total billed charges,60% of total billed charges,6.24,48,,4.992,percent of total billed charges,48% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,9.1,70,,7.28,percent of total billed charges,70% of total billed charges,6.3,48.48,,5.04,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,6.3,48.48,,5.04,percent of total billed charges,48.48% of total billed charges,9.1,70,,7.28,percent of total billed charges,70% of total billed charges,9.1,70,,7.28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,6.3,48.48,,5.04,percent of total billed charges,48.48% of total billed charges,11.7,90,,9.36,percent of total billed charges,90% of total billed charges,6.3,90,
NOC^ NITROGLYCERIN/ D5W PREMIX,,,250,RC,J3490,HCPCS,outpatient,1,UN,91,54.60,,54.6,60,,43.68,percent of total billed charges,60% of total billed charges,43.68,48,,34.944,percent of total billed charges,48% of total billed charges,45.5,50,,36.4,percent of total billed charges,50% of total billed charges,45.5,50,,36.4,percent of total billed charges,50% of total billed charges,45.5,50,,36.4,percent of total billed charges,50% of total billed charges,45.5,50,,36.4,percent of total billed charges,50% of total billed charges,63.7,70,,50.96,percent of total billed charges,70% of total billed charges,44.12,48.48,,35.296,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,44.12,48.48,,35.296,percent of total billed charges,48.48% of total billed charges,63.7,70,,50.96,percent of total billed charges,70% of total billed charges,63.7,70,,50.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,44.12,48.48,,35.296,percent of total billed charges,48.48% of total billed charges,81.9,90,,65.52,percent of total billed charges,90% of total billed charges,44.12,90,
NOC^ PILOCARPINE 2% [EYE],,,259,RC,J3490,HCPCS,outpatient,1,UN,128,76.80,,76.8,60,,61.44,percent of total billed charges,60% of total billed charges,61.44,48,,49.152,percent of total billed charges,48% of total billed charges,64,50,,51.2,percent of total billed charges,50% of total billed charges,64,50,,51.2,percent of total billed charges,50% of total billed charges,64,50,,51.2,percent of total billed charges,50% of total billed charges,64,50,,51.2,percent of total billed charges,50% of total billed charges,89.6,70,,71.68,percent of total billed charges,70% of total billed charges,62.05,48.48,,49.64,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,62.05,48.48,,49.64,percent of total billed charges,48.48% of total billed charges,89.6,70,,71.68,percent of total billed charges,70% of total billed charges,89.6,70,,71.68,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,62.05,48.48,,49.64,percent of total billed charges,48.48% of total billed charges,115.2,90,,92.16,percent of total billed charges,90% of total billed charges,48.48,115.2,
OMNICEF SUSP 250MG 60ML,,,259,RC,,,outpatient,,,232.1,139.26,,139.26,60,,111.408,percent of total billed charges,60% of total billed charges,111.41,48,,89.128,percent of total billed charges,48% of total billed charges,116.05,50,,92.84,percent of total billed charges,50% of total billed charges,116.05,50,,92.84,percent of total billed charges,50% of total billed charges,116.05,50,,92.84,percent of total billed charges,50% of total billed charges,116.05,50,,92.84,percent of total billed charges,50% of total billed charges,162.47,70,,129.976,percent of total billed charges,70% of total billed charges,112.52,48.48,,90.016,percent of total billed charges,48.48% of total billed charges,112.52,48.48,,90.016,percent of total billed charges,48.48% of total billed charges,112.52,48.48,,90.016,percent of total billed charges,48.48% of total billed charges,162.47,70,,129.976,percent of total billed charges,70% of total billed charges,162.47,70,,129.976,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,112.52,48.48,,90.016,percent of total billed charges,48.48% of total billed charges,208.89,90,,167.112,percent of total billed charges,90% of total billed charges,48.48,208.89,
LEVOFLOXACIN 500MG IV PMX,,,636,RC,J1956,HCPCS,outpatient,2,UN,67,40.20,,40.2,60,,32.16,percent of total billed charges,60% of total billed charges,32.16,48,,25.728,percent of total billed charges,48% of total billed charges,0.44,100,,,fee schedule,100% of bcbs custom fee schedule,0.44,100,,,fee schedule,100% of bcbs custom fee schedule,0.49,111,,,fee schedule,111% of bcbs custom fee schedule,33.5,50,,26.8,percent of total billed charges,50% of total billed charges,46.9,70,,37.52,percent of total billed charges,70% of total billed charges,32.48,48.48,,25.984,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,32.48,48.48,,25.984,percent of total billed charges,48.48% of total billed charges,46.9,70,,37.52,percent of total billed charges,70% of total billed charges,46.9,70,,37.52,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,32.48,48.48,,25.984,percent of total billed charges,48.48% of total billed charges,60.3,90,,48.24,percent of total billed charges,90% of total billed charges,32.48,90,
NOC^ LEVOFLOXACIN TAB [500 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,104,62.40,,62.4,60,,49.92,percent of total billed charges,60% of total billed charges,49.92,48,,39.936,percent of total billed charges,48% of total billed charges,52,50,,41.6,percent of total billed charges,50% of total billed charges,52,50,,41.6,percent of total billed charges,50% of total billed charges,52,50,,41.6,percent of total billed charges,50% of total billed charges,52,50,,41.6,percent of total billed charges,50% of total billed charges,72.8,70,,58.24,percent of total billed charges,70% of total billed charges,50.42,48.48,,40.336,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,50.42,48.48,,40.336,percent of total billed charges,48.48% of total billed charges,72.8,70,,58.24,percent of total billed charges,70% of total billed charges,72.8,70,,58.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,50.42,48.48,,40.336,percent of total billed charges,48.48% of total billed charges,93.6,90,,74.88,percent of total billed charges,90% of total billed charges,48.48,93.6,
FUROSEMIDE INJ [40 MG/4ML,,,636,RC,J1940,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,0.87,100,,,fee schedule,100% of bcbs custom fee schedule,0.87,100,,,fee schedule,100% of bcbs custom fee schedule,0.97,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
DIGOXIN INJ [0.25 MG/ML],,,636,RC,J1160,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,6.2,100,,,fee schedule,100% of bcbs custom fee schedule,6.2,100,,,fee schedule,100% of bcbs custom fee schedule,6.88,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
NOC^ AMMON LACTATE 12% CRM,,,259,RC,J3490,HCPCS,outpatient,1,UN,73,43.80,,43.8,60,,35.04,percent of total billed charges,60% of total billed charges,35.04,48,,28.032,percent of total billed charges,48% of total billed charges,36.5,50,,29.2,percent of total billed charges,50% of total billed charges,36.5,50,,29.2,percent of total billed charges,50% of total billed charges,36.5,50,,29.2,percent of total billed charges,50% of total billed charges,36.5,50,,29.2,percent of total billed charges,50% of total billed charges,51.1,70,,40.88,percent of total billed charges,70% of total billed charges,35.39,48.48,,28.312,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,35.39,48.48,,28.312,percent of total billed charges,48.48% of total billed charges,51.1,70,,40.88,percent of total billed charges,70% of total billed charges,51.1,70,,40.88,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,35.39,48.48,,28.312,percent of total billed charges,48.48% of total billed charges,65.7,90,,52.56,percent of total billed charges,90% of total billed charges,35.39,90,
FUROSEMIDE INJ [20MG/2ML),,,636,RC,J1940,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,0.87,100,,,fee schedule,100% of bcbs custom fee schedule,0.87,100,,,fee schedule,100% of bcbs custom fee schedule,0.97,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
NOC^ CHLORDIAZPX W/CLID CAP,,,259,RC,J3490,HCPCS,outpatient,1,UN,238,142.80,,142.8,60,,114.24,percent of total billed charges,60% of total billed charges,114.24,48,,91.392,percent of total billed charges,48% of total billed charges,119,50,,95.2,percent of total billed charges,50% of total billed charges,119,50,,95.2,percent of total billed charges,50% of total billed charges,119,50,,95.2,percent of total billed charges,50% of total billed charges,119,50,,95.2,percent of total billed charges,50% of total billed charges,166.6,70,,133.28,percent of total billed charges,70% of total billed charges,115.38,48.48,,92.304,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,115.38,48.48,,92.304,percent of total billed charges,48.48% of total billed charges,166.6,70,,133.28,percent of total billed charges,70% of total billed charges,166.6,70,,133.28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,115.38,48.48,,92.304,percent of total billed charges,48.48% of total billed charges,214.2,90,,171.36,percent of total billed charges,90% of total billed charges,48.48,214.2,
NOC^ ATORVASTATIN TAB [20 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,31,18.60,,18.6,60,,14.88,percent of total billed charges,60% of total billed charges,14.88,48,,11.904,percent of total billed charges,48% of total billed charges,15.5,50,,12.4,percent of total billed charges,50% of total billed charges,15.5,50,,12.4,percent of total billed charges,50% of total billed charges,15.5,50,,12.4,percent of total billed charges,50% of total billed charges,15.5,50,,12.4,percent of total billed charges,50% of total billed charges,21.7,70,,17.36,percent of total billed charges,70% of total billed charges,15.03,48.48,,12.024,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,15.03,48.48,,12.024,percent of total billed charges,48.48% of total billed charges,21.7,70,,17.36,percent of total billed charges,70% of total billed charges,21.7,70,,17.36,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,15.03,48.48,,12.024,percent of total billed charges,48.48% of total billed charges,27.9,90,,22.32,percent of total billed charges,90% of total billed charges,15.03,90,
NOC^ ESCITALOPRAM TAB [10 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,18,10.80,,10.8,60,,8.64,percent of total billed charges,60% of total billed charges,8.64,48,,6.912,percent of total billed charges,48% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,12.6,70,,10.08,percent of total billed charges,70% of total billed charges,8.73,48.48,,6.984,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,8.73,48.48,,6.984,percent of total billed charges,48.48% of total billed charges,12.6,70,,10.08,percent of total billed charges,70% of total billed charges,12.6,70,,10.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,8.73,48.48,,6.984,percent of total billed charges,48.48% of total billed charges,16.2,90,,12.96,percent of total billed charges,90% of total billed charges,8.73,90,
NOC^ FLUOCINONIDE 0.05% CRM,,,259,RC,J3490,HCPCS,outpatient,1,UN,55,33.00,,33,60,,26.4,percent of total billed charges,60% of total billed charges,26.4,48,,21.12,percent of total billed charges,48% of total billed charges,27.5,50,,22,percent of total billed charges,50% of total billed charges,27.5,50,,22,percent of total billed charges,50% of total billed charges,27.5,50,,22,percent of total billed charges,50% of total billed charges,27.5,50,,22,percent of total billed charges,50% of total billed charges,38.5,70,,30.8,percent of total billed charges,70% of total billed charges,26.66,48.48,,21.328,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,26.66,48.48,,21.328,percent of total billed charges,48.48% of total billed charges,38.5,70,,30.8,percent of total billed charges,70% of total billed charges,38.5,70,,30.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,26.66,48.48,,21.328,percent of total billed charges,48.48% of total billed charges,49.5,90,,39.6,percent of total billed charges,90% of total billed charges,26.66,90,
NOC^ LANTISEPTIC CRM 4 OZ,,,257,RC,J3490,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
NOC^ CLOTRIMAZOLE 1% CRM,,,259,RC,J3490,HCPCS,outpatient,1,UN,35,21.00,,21,60,,16.8,percent of total billed charges,60% of total billed charges,16.8,48,,13.44,percent of total billed charges,48% of total billed charges,17.5,50,,14,percent of total billed charges,50% of total billed charges,17.5,50,,14,percent of total billed charges,50% of total billed charges,17.5,50,,14,percent of total billed charges,50% of total billed charges,17.5,50,,14,percent of total billed charges,50% of total billed charges,24.5,70,,19.6,percent of total billed charges,70% of total billed charges,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,24.5,70,,19.6,percent of total billed charges,70% of total billed charges,24.5,70,,19.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,31.5,90,,25.2,percent of total billed charges,90% of total billed charges,16.97,90,
NOC^ CALCITONIN NAS SPR [200 U,,,259,RC,J3490,HCPCS,outpatient,1,UN,475,285.00,,285,60,,228,percent of total billed charges,60% of total billed charges,228,48,,182.4,percent of total billed charges,48% of total billed charges,237.5,50,,190,percent of total billed charges,50% of total billed charges,237.5,50,,190,percent of total billed charges,50% of total billed charges,237.5,50,,190,percent of total billed charges,50% of total billed charges,237.5,50,,190,percent of total billed charges,50% of total billed charges,332.5,70,,266,percent of total billed charges,70% of total billed charges,230.28,48.48,,184.224,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,230.28,48.48,,184.224,percent of total billed charges,48.48% of total billed charges,332.5,70,,266,percent of total billed charges,70% of total billed charges,332.5,70,,266,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,230.28,48.48,,184.224,percent of total billed charges,48.48% of total billed charges,427.5,90,,342,percent of total billed charges,90% of total billed charges,48.48,427.5,
ENOXAPARIN INJ SYR [100 M,,,636,RC,J1650,HCPCS,outpatient,1,UN,72,43.20,,43.2,60,,34.56,percent of total billed charges,60% of total billed charges,34.56,48,,27.648,percent of total billed charges,48% of total billed charges,0.76,100,,,fee schedule,100% of bcbs custom fee schedule,0.76,100,,,fee schedule,100% of bcbs custom fee schedule,0.84,111,,,fee schedule,111% of bcbs custom fee schedule,36,50,,28.8,percent of total billed charges,50% of total billed charges,50.4,70,,40.32,percent of total billed charges,70% of total billed charges,34.91,48.48,,27.928,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,34.91,48.48,,27.928,percent of total billed charges,48.48% of total billed charges,50.4,70,,40.32,percent of total billed charges,70% of total billed charges,50.4,70,,40.32,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,34.91,48.48,,27.928,percent of total billed charges,48.48% of total billed charges,64.8,90,,51.84,percent of total billed charges,90% of total billed charges,34.91,90,
ENOXAPARIN INJ [40 MG/0.4,,,636,RC,J1650,HCPCS,outpatient,1,UN,72,43.20,,43.2,60,,34.56,percent of total billed charges,60% of total billed charges,34.56,48,,27.648,percent of total billed charges,48% of total billed charges,0.76,100,,,fee schedule,100% of bcbs custom fee schedule,0.76,100,,,fee schedule,100% of bcbs custom fee schedule,0.84,111,,,fee schedule,111% of bcbs custom fee schedule,36,50,,28.8,percent of total billed charges,50% of total billed charges,50.4,70,,40.32,percent of total billed charges,70% of total billed charges,34.91,48.48,,27.928,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,34.91,48.48,,27.928,percent of total billed charges,48.48% of total billed charges,50.4,70,,40.32,percent of total billed charges,70% of total billed charges,50.4,70,,40.32,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,34.91,48.48,,27.928,percent of total billed charges,48.48% of total billed charges,64.8,90,,51.84,percent of total billed charges,90% of total billed charges,34.91,90,
ENOXAPARIN INJ SYR [30 MG,,,636,RC,J1650,HCPCS,outpatient,1,UN,72,43.20,,43.2,60,,34.56,percent of total billed charges,60% of total billed charges,34.56,48,,27.648,percent of total billed charges,48% of total billed charges,0.76,100,,,fee schedule,100% of bcbs custom fee schedule,0.76,100,,,fee schedule,100% of bcbs custom fee schedule,0.84,111,,,fee schedule,111% of bcbs custom fee schedule,36,50,,28.8,percent of total billed charges,50% of total billed charges,50.4,70,,40.32,percent of total billed charges,70% of total billed charges,34.91,48.48,,27.928,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,34.91,48.48,,27.928,percent of total billed charges,48.48% of total billed charges,50.4,70,,40.32,percent of total billed charges,70% of total billed charges,50.4,70,,40.32,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,34.91,48.48,,27.928,percent of total billed charges,48.48% of total billed charges,64.8,90,,51.84,percent of total billed charges,90% of total billed charges,34.91,90,
NOC^ SILVER SULFADIAZINE 25 GM,,,259,RC,J3490,HCPCS,outpatient,1,UN,36,21.60,,21.6,60,,17.28,percent of total billed charges,60% of total billed charges,17.28,48,,13.824,percent of total billed charges,48% of total billed charges,18,50,,14.4,percent of total billed charges,50% of total billed charges,18,50,,14.4,percent of total billed charges,50% of total billed charges,18,50,,14.4,percent of total billed charges,50% of total billed charges,18,50,,14.4,percent of total billed charges,50% of total billed charges,25.2,70,,20.16,percent of total billed charges,70% of total billed charges,17.45,48.48,,13.96,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,17.45,48.48,,13.96,percent of total billed charges,48.48% of total billed charges,25.2,70,,20.16,percent of total billed charges,70% of total billed charges,25.2,70,,20.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,17.45,48.48,,13.96,percent of total billed charges,48.48% of total billed charges,32.4,90,,25.92,percent of total billed charges,90% of total billed charges,17.45,90,
NOC^ AMLOD/BENAZ CAP 5-20 MG,,,259,RC,J3490,HCPCS,outpatient,1,UN,12,7.20,,7.2,60,,5.76,percent of total billed charges,60% of total billed charges,5.76,48,,4.608,percent of total billed charges,48% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,8.4,70,,6.72,percent of total billed charges,70% of total billed charges,5.82,48.48,,4.656,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,5.82,48.48,,4.656,percent of total billed charges,48.48% of total billed charges,8.4,70,,6.72,percent of total billed charges,70% of total billed charges,8.4,70,,6.72,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,5.82,48.48,,4.656,percent of total billed charges,48.48% of total billed charges,10.8,90,,8.64,percent of total billed charges,90% of total billed charges,5.82,90,
LAMISIL CREAM 1% 15GM,,,259,RC,,,outpatient,,,40,24.00,,24,60,,19.2,percent of total billed charges,60% of total billed charges,19.2,48,,15.36,percent of total billed charges,48% of total billed charges,20,50,,16,percent of total billed charges,50% of total billed charges,20,50,,16,percent of total billed charges,50% of total billed charges,20,50,,16,percent of total billed charges,50% of total billed charges,20,50,,16,percent of total billed charges,50% of total billed charges,28,70,,22.4,percent of total billed charges,70% of total billed charges,19.39,48.48,,15.512,percent of total billed charges,48.48% of total billed charges,19.39,48.48,,15.512,percent of total billed charges,48.48% of total billed charges,19.39,48.48,,15.512,percent of total billed charges,48.48% of total billed charges,28,70,,22.4,percent of total billed charges,70% of total billed charges,28,70,,22.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,19.39,48.48,,15.512,percent of total billed charges,48.48% of total billed charges,36,90,,28.8,percent of total billed charges,90% of total billed charges,19.39,90,
NOC^ TERBINAFINE 1% CRM,,,259,RC,J3490,HCPCS,outpatient,1,UN,49,29.40,,29.4,60,,23.52,percent of total billed charges,60% of total billed charges,23.52,48,,18.816,percent of total billed charges,48% of total billed charges,24.5,50,,19.6,percent of total billed charges,50% of total billed charges,24.5,50,,19.6,percent of total billed charges,50% of total billed charges,24.5,50,,19.6,percent of total billed charges,50% of total billed charges,24.5,50,,19.6,percent of total billed charges,50% of total billed charges,34.3,70,,27.44,percent of total billed charges,70% of total billed charges,23.76,48.48,,19.008,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,23.76,48.48,,19.008,percent of total billed charges,48.48% of total billed charges,34.3,70,,27.44,percent of total billed charges,70% of total billed charges,34.3,70,,27.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,23.76,48.48,,19.008,percent of total billed charges,48.48% of total billed charges,44.1,90,,35.28,percent of total billed charges,90% of total billed charges,23.76,90,
NOC^ TERBINAFINE TAB [250 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,52,31.20,,31.2,60,,24.96,percent of total billed charges,60% of total billed charges,24.96,48,,19.968,percent of total billed charges,48% of total billed charges,26,50,,20.8,percent of total billed charges,50% of total billed charges,26,50,,20.8,percent of total billed charges,50% of total billed charges,26,50,,20.8,percent of total billed charges,50% of total billed charges,26,50,,20.8,percent of total billed charges,50% of total billed charges,36.4,70,,29.12,percent of total billed charges,70% of total billed charges,25.21,48.48,,20.168,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,25.21,48.48,,20.168,percent of total billed charges,48.48% of total billed charges,36.4,70,,29.12,percent of total billed charges,70% of total billed charges,36.4,70,,29.12,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,25.21,48.48,,20.168,percent of total billed charges,48.48% of total billed charges,46.8,90,,37.44,percent of total billed charges,90% of total billed charges,25.21,90,
NOC^ ATORVASTATIN TAB [10 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,22,13.20,,13.2,60,,10.56,percent of total billed charges,60% of total billed charges,10.56,48,,8.448,percent of total billed charges,48% of total billed charges,11,50,,8.8,percent of total billed charges,50% of total billed charges,11,50,,8.8,percent of total billed charges,50% of total billed charges,11,50,,8.8,percent of total billed charges,50% of total billed charges,11,50,,8.8,percent of total billed charges,50% of total billed charges,15.4,70,,12.32,percent of total billed charges,70% of total billed charges,10.67,48.48,,8.536,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,10.67,48.48,,8.536,percent of total billed charges,48.48% of total billed charges,15.4,70,,12.32,percent of total billed charges,70% of total billed charges,15.4,70,,12.32,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,10.67,48.48,,8.536,percent of total billed charges,48.48% of total billed charges,19.8,90,,15.84,percent of total billed charges,90% of total billed charges,10.67,90,
NOC^ MICONAZOLE 2% CRM,,,257,RC,J3490,HCPCS,outpatient,1,UN,29,17.40,,17.4,60,,13.92,percent of total billed charges,60% of total billed charges,13.92,48,,11.136,percent of total billed charges,48% of total billed charges,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,20.3,70,,16.24,percent of total billed charges,70% of total billed charges,14.06,48.48,,11.248,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,14.06,48.48,,11.248,percent of total billed charges,48.48% of total billed charges,20.3,70,,16.24,percent of total billed charges,70% of total billed charges,20.3,70,,16.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,14.06,48.48,,11.248,percent of total billed charges,48.48% of total billed charges,26.1,90,,20.88,percent of total billed charges,90% of total billed charges,14.06,90,
NOC^ GABAPENTIN CAP [400 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,11,6.60,,6.6,60,,5.28,percent of total billed charges,60% of total billed charges,5.28,48,,4.224,percent of total billed charges,48% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,9.9,90,,7.92,percent of total billed charges,90% of total billed charges,5.33,90,
NOC^ GABAPENTIN TAB 600 MG,,,259,RC,J8499,HCPCS,outpatient,1,UN,11,6.60,,6.6,60,,5.28,percent of total billed charges,60% of total billed charges,5.28,48,,4.224,percent of total billed charges,48% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,9.9,90,,7.92,percent of total billed charges,90% of total billed charges,5.33,90,
MICONAZOLE 3 VAG SUPP,,,257,RC,,,outpatient,,,211,126.60,,126.6,60,,101.28,percent of total billed charges,60% of total billed charges,101.28,48,,81.024,percent of total billed charges,48% of total billed charges,105.5,50,,84.4,percent of total billed charges,50% of total billed charges,105.5,50,,84.4,percent of total billed charges,50% of total billed charges,105.5,50,,84.4,percent of total billed charges,50% of total billed charges,105.5,50,,84.4,percent of total billed charges,50% of total billed charges,147.7,70,,118.16,percent of total billed charges,70% of total billed charges,102.29,48.48,,81.832,percent of total billed charges,48.48% of total billed charges,102.29,48.48,,81.832,percent of total billed charges,48.48% of total billed charges,102.29,48.48,,81.832,percent of total billed charges,48.48% of total billed charges,147.7,70,,118.16,percent of total billed charges,70% of total billed charges,147.7,70,,118.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,102.29,48.48,,81.832,percent of total billed charges,48.48% of total billed charges,189.9,90,,151.92,percent of total billed charges,90% of total billed charges,48.48,189.9,
NOC^ NITROFURANTOIN CAP [50 MG,,,259,RC,J8499,HCPCS,outpatient,1,UN,11.05,6.63,,6.63,60,,5.304,percent of total billed charges,60% of total billed charges,5.3,48,,4.24,percent of total billed charges,48% of total billed charges,5.53,50,,4.424,percent of total billed charges,50% of total billed charges,5.53,50,,4.424,percent of total billed charges,50% of total billed charges,5.53,50,,4.424,percent of total billed charges,50% of total billed charges,5.53,50,,4.424,percent of total billed charges,50% of total billed charges,7.74,70,,6.192,percent of total billed charges,70% of total billed charges,5.36,48.48,,4.288,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,5.36,48.48,,4.288,percent of total billed charges,48.48% of total billed charges,7.74,70,,6.192,percent of total billed charges,70% of total billed charges,7.74,70,,6.192,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,5.36,48.48,,4.288,percent of total billed charges,48.48% of total billed charges,9.95,90,,7.96,percent of total billed charges,90% of total billed charges,5.36,90,
MAG SULF INJ [5 GM/10ML],,,250,RC,J3475,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,0.46,100,,,fee schedule,100% of bcbs custom fee schedule,0.46,100,,,fee schedule,100% of bcbs custom fee schedule,0.51,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
MANNITOL 25% INJ [50ML],,,636,RC,J2150,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,2.28,100,,,fee schedule,100% of bcbs custom fee schedule,2.28,100,,,fee schedule,100% of bcbs custom fee schedule,2.53,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
LANTUS INSULIN INJ,,,250,RC,,,outpatient,,,16.5,9.90,,9.9,60,,7.92,percent of total billed charges,60% of total billed charges,7.92,48,,6.336,percent of total billed charges,48% of total billed charges,8.25,50,,6.6,percent of total billed charges,50% of total billed charges,8.25,50,,6.6,percent of total billed charges,50% of total billed charges,8.25,50,,6.6,percent of total billed charges,50% of total billed charges,8.25,50,,6.6,percent of total billed charges,50% of total billed charges,11.55,70,,9.24,percent of total billed charges,70% of total billed charges,8,48.48,,6.4,percent of total billed charges,48.48% of total billed charges,8,48.48,,6.4,percent of total billed charges,48.48% of total billed charges,8,48.48,,6.4,percent of total billed charges,48.48% of total billed charges,11.55,70,,9.24,percent of total billed charges,70% of total billed charges,11.55,70,,9.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,8,48.48,,6.4,percent of total billed charges,48.48% of total billed charges,14.85,90,,11.88,percent of total billed charges,90% of total billed charges,8,90,
BUPIVACAINE 0.5% INJ,,,250,RC,J0665,HCPCS,outpatient,1,UN,22,13.20,,13.2,60,,10.56,percent of total billed charges,60% of total billed charges,10.56,48,,8.448,percent of total billed charges,48% of total billed charges,11,50,,8.8,percent of total billed charges,50% of total billed charges,11,50,,8.8,percent of total billed charges,50% of total billed charges,11,50,,8.8,percent of total billed charges,50% of total billed charges,11,50,,8.8,percent of total billed charges,50% of total billed charges,15.4,70,,12.32,percent of total billed charges,70% of total billed charges,10.67,48.48,,8.536,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,10.67,48.48,,8.536,percent of total billed charges,48.48% of total billed charges,15.4,70,,12.32,percent of total billed charges,70% of total billed charges,15.4,70,,12.32,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,10.67,48.48,,8.536,percent of total billed charges,48.48% of total billed charges,19.8,90,,15.84,percent of total billed charges,90% of total billed charges,10.67,90,
NOC^ AQUA-MEPHYTON TAB [5 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,46,27.60,,27.6,60,,22.08,percent of total billed charges,60% of total billed charges,22.08,48,,17.664,percent of total billed charges,48% of total billed charges,23,50,,18.4,percent of total billed charges,50% of total billed charges,23,50,,18.4,percent of total billed charges,50% of total billed charges,23,50,,18.4,percent of total billed charges,50% of total billed charges,23,50,,18.4,percent of total billed charges,50% of total billed charges,32.2,70,,25.76,percent of total billed charges,70% of total billed charges,22.3,48.48,,17.84,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,22.3,48.48,,17.84,percent of total billed charges,48.48% of total billed charges,32.2,70,,25.76,percent of total billed charges,70% of total billed charges,32.2,70,,25.76,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,22.3,48.48,,17.84,percent of total billed charges,48.48% of total billed charges,41.4,90,,33.12,percent of total billed charges,90% of total billed charges,22.3,90,
METHYLPREDNISOL PKG 4 MG,,,259,RC,J7509,HCPCS,outpatient,1,UN,139,83.40,,83.4,60,,66.72,percent of total billed charges,60% of total billed charges,66.72,48,,53.376,percent of total billed charges,48% of total billed charges,0.28,100,,,fee schedule,100% of bcbs custom fee schedule,0.28,100,,,fee schedule,100% of bcbs custom fee schedule,0.31,111,,,fee schedule,111% of bcbs custom fee schedule,69.5,50,,55.6,percent of total billed charges,50% of total billed charges,97.3,70,,77.84,percent of total billed charges,70% of total billed charges,67.39,48.48,,53.912,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,67.39,48.48,,53.912,percent of total billed charges,48.48% of total billed charges,97.3,70,,77.84,percent of total billed charges,70% of total billed charges,97.3,70,,77.84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,67.39,48.48,,53.912,percent of total billed charges,48.48% of total billed charges,125.1,90,,100.08,percent of total billed charges,90% of total billed charges,48.48,125.1,
NOC^ MEGESTROL ES SUS 625MG/5M,,,259,RC,J3490,HCPCS,outpatient,1,UN,161,96.60,,96.6,60,,77.28,percent of total billed charges,60% of total billed charges,77.28,48,,61.824,percent of total billed charges,48% of total billed charges,80.5,50,,64.4,percent of total billed charges,50% of total billed charges,80.5,50,,64.4,percent of total billed charges,50% of total billed charges,80.5,50,,64.4,percent of total billed charges,50% of total billed charges,80.5,50,,64.4,percent of total billed charges,50% of total billed charges,112.7,70,,90.16,percent of total billed charges,70% of total billed charges,78.05,48.48,,62.44,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,78.05,48.48,,62.44,percent of total billed charges,48.48% of total billed charges,112.7,70,,90.16,percent of total billed charges,70% of total billed charges,112.7,70,,90.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,78.05,48.48,,62.44,percent of total billed charges,48.48% of total billed charges,144.9,90,,115.92,percent of total billed charges,90% of total billed charges,48.48,144.9,
MENINGOCOCCAL VACC 0.5 ML,43601424,CDM,636,RC,90734,HCPCS,outpatient,1,UN,337,202.20,,202.2,60,,161.76,percent of total billed charges,60% of total billed charges,161.76,48,,129.408,percent of total billed charges,48% of total billed charges,146.21,100,,,fee schedule,100% of bcbs custom fee schedule,146.21,100,,,fee schedule,100% of bcbs custom fee schedule,162.29,111,,,fee schedule,111% of bcbs custom fee schedule,168.5,50,,134.8,percent of total billed charges,50% of total billed charges,235.9,70,,188.72,percent of total billed charges,70% of total billed charges,163.38,48.48,,130.704,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,163.38,48.48,,130.704,percent of total billed charges,48.48% of total billed charges,235.9,70,,188.72,percent of total billed charges,70% of total billed charges,235.9,70,,188.72,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,163.38,48.48,,130.704,percent of total billed charges,48.48% of total billed charges,303.3,90,,242.64,percent of total billed charges,90% of total billed charges,48.48,303.3,
NOC^ PRAMIPEXOLE TAB 0.25 MG,,,259,RC,J8499,HCPCS,outpatient,1,UN,12,7.20,,7.2,60,,5.76,percent of total billed charges,60% of total billed charges,5.76,48,,4.608,percent of total billed charges,48% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,8.4,70,,6.72,percent of total billed charges,70% of total billed charges,5.82,48.48,,4.656,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,5.82,48.48,,4.656,percent of total billed charges,48.48% of total billed charges,8.4,70,,6.72,percent of total billed charges,70% of total billed charges,8.4,70,,6.72,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,5.82,48.48,,4.656,percent of total billed charges,48.48% of total billed charges,10.8,90,,8.64,percent of total billed charges,90% of total billed charges,5.82,90,
NEO/POLY-B/DEX SUSP 5ML,,,259,RC,,,outpatient,,,80,48.00,,48,60,,38.4,percent of total billed charges,60% of total billed charges,38.4,48,,30.72,percent of total billed charges,48% of total billed charges,40,50,,32,percent of total billed charges,50% of total billed charges,40,50,,32,percent of total billed charges,50% of total billed charges,40,50,,32,percent of total billed charges,50% of total billed charges,40,50,,32,percent of total billed charges,50% of total billed charges,56,70,,44.8,percent of total billed charges,70% of total billed charges,38.78,48.48,,31.024,percent of total billed charges,48.48% of total billed charges,38.78,48.48,,31.024,percent of total billed charges,48.48% of total billed charges,38.78,48.48,,31.024,percent of total billed charges,48.48% of total billed charges,56,70,,44.8,percent of total billed charges,70% of total billed charges,56,70,,44.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,38.78,48.48,,31.024,percent of total billed charges,48.48% of total billed charges,72,90,,57.6,percent of total billed charges,90% of total billed charges,38.78,90,
PRAMIPEXOLE TAB [1 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,12,7.20,,7.2,60,,5.76,percent of total billed charges,60% of total billed charges,5.76,48,,4.608,percent of total billed charges,48% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,8.4,70,,6.72,percent of total billed charges,70% of total billed charges,5.82,48.48,,4.656,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,5.82,48.48,,4.656,percent of total billed charges,48.48% of total billed charges,8.4,70,,6.72,percent of total billed charges,70% of total billed charges,8.4,70,,6.72,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,5.82,48.48,,4.656,percent of total billed charges,48.48% of total billed charges,10.8,90,,8.64,percent of total billed charges,90% of total billed charges,5.82,90,
NOC^ POLYETHYLENE GLYC [17 GM),,,259,RC,J3490,HCPCS,outpatient,1,UN,13,7.80,,7.8,60,,6.24,percent of total billed charges,60% of total billed charges,6.24,48,,4.992,percent of total billed charges,48% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,9.1,70,,7.28,percent of total billed charges,70% of total billed charges,6.3,48.48,,5.04,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,6.3,48.48,,5.04,percent of total billed charges,48.48% of total billed charges,9.1,70,,7.28,percent of total billed charges,70% of total billed charges,9.1,70,,7.28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,6.3,48.48,,5.04,percent of total billed charges,48.48% of total billed charges,11.7,90,,9.36,percent of total billed charges,90% of total billed charges,6.3,90,
NOC^ FENTANYL PAT [50 MCG/HR],,,250,RC,J3490,HCPCS,outpatient,1,UN,106,63.60,,63.6,60,,50.88,percent of total billed charges,60% of total billed charges,50.88,48,,40.704,percent of total billed charges,48% of total billed charges,53,50,,42.4,percent of total billed charges,50% of total billed charges,53,50,,42.4,percent of total billed charges,50% of total billed charges,53,50,,42.4,percent of total billed charges,50% of total billed charges,53,50,,42.4,percent of total billed charges,50% of total billed charges,74.2,70,,59.36,percent of total billed charges,70% of total billed charges,51.39,48.48,,41.112,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,51.39,48.48,,41.112,percent of total billed charges,48.48% of total billed charges,74.2,70,,59.36,percent of total billed charges,70% of total billed charges,74.2,70,,59.36,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,51.39,48.48,,41.112,percent of total billed charges,48.48% of total billed charges,95.4,90,,76.32,percent of total billed charges,90% of total billed charges,48.48,95.4,
MORPHINE INJ [10 MG/ML],43601516,CDM,250,RC,J2270,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,2.06,100,,,fee schedule,100% of bcbs custom fee schedule,2.06,100,,,fee schedule,100% of bcbs custom fee schedule,2.29,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
ACETYLCYSTEINE SOL 10%,43104056,CDM,250,RC,J7608,HCPCS,outpatient,1,UN,40,24.00,,24,60,,19.2,percent of total billed charges,60% of total billed charges,19.2,48,,15.36,percent of total billed charges,48% of total billed charges,6.51,100,,,fee schedule,100% of bcbs custom fee schedule,6.51,100,,,fee schedule,100% of bcbs custom fee schedule,7.23,111,,,fee schedule,111% of bcbs custom fee schedule,20,50,,16,percent of total billed charges,50% of total billed charges,28,70,,22.4,percent of total billed charges,70% of total billed charges,19.39,48.48,,15.512,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,19.39,48.48,,15.512,percent of total billed charges,48.48% of total billed charges,28,70,,22.4,percent of total billed charges,70% of total billed charges,28,70,,22.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,19.39,48.48,,15.512,percent of total billed charges,48.48% of total billed charges,36,90,,28.8,percent of total billed charges,90% of total billed charges,19.39,90,
NOC^ LOVASTATIN TAB [20 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,16,9.60,,9.6,60,,7.68,percent of total billed charges,60% of total billed charges,7.68,48,,6.144,percent of total billed charges,48% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,11.2,70,,8.96,percent of total billed charges,70% of total billed charges,7.76,48.48,,6.208,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,7.76,48.48,,6.208,percent of total billed charges,48.48% of total billed charges,11.2,70,,8.96,percent of total billed charges,70% of total billed charges,11.2,70,,8.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,7.76,48.48,,6.208,percent of total billed charges,48.48% of total billed charges,14.4,90,,11.52,percent of total billed charges,90% of total billed charges,7.76,90,
NOC^ ERYTHROMYCIN EYE OIN,,,259,RC,J3490,HCPCS,outpatient,1,UN,75,45.00,,45,60,,36,percent of total billed charges,60% of total billed charges,36,48,,28.8,percent of total billed charges,48% of total billed charges,37.5,50,,30,percent of total billed charges,50% of total billed charges,37.5,50,,30,percent of total billed charges,50% of total billed charges,37.5,50,,30,percent of total billed charges,50% of total billed charges,37.5,50,,30,percent of total billed charges,50% of total billed charges,52.5,70,,42,percent of total billed charges,70% of total billed charges,36.36,48.48,,29.088,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,36.36,48.48,,29.088,percent of total billed charges,48.48% of total billed charges,52.5,70,,42,percent of total billed charges,70% of total billed charges,52.5,70,,42,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,36.36,48.48,,29.088,percent of total billed charges,48.48% of total billed charges,67.5,90,,54,percent of total billed charges,90% of total billed charges,36.36,90,
MEMANTINE TAB 10 MG,,,251,RC,J8499,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
MEMANTINE TAB 5 MG,,,259,RC,J8499,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
NALOXONE INJ [0.4 MG/ML],43601517,CDM,250,RC,J2310,HCPCS,outpatient,1,UN,76,45.60,,45.6,60,,36.48,percent of total billed charges,60% of total billed charges,36.48,48,,29.184,percent of total billed charges,48% of total billed charges,12.13,100,,,fee schedule,100% of bcbs custom fee schedule,12.13,100,,,fee schedule,100% of bcbs custom fee schedule,13.46,111,,,fee schedule,111% of bcbs custom fee schedule,38,50,,30.4,percent of total billed charges,50% of total billed charges,53.2,70,,42.56,percent of total billed charges,70% of total billed charges,36.84,48.48,,29.472,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,36.84,48.48,,29.472,percent of total billed charges,48.48% of total billed charges,53.2,70,,42.56,percent of total billed charges,70% of total billed charges,53.2,70,,42.56,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,36.84,48.48,,29.472,percent of total billed charges,48.48% of total billed charges,68.4,90,,54.72,percent of total billed charges,90% of total billed charges,36.84,90,
NEUPOGEN INJ 300MCG,,,636,RC,J1442,HCPCS,outpatient,1,UN,1602,961.20,,961.2,60,,768.96,percent of total billed charges,60% of total billed charges,768.96,48,,615.168,percent of total billed charges,48% of total billed charges,0.52,100,,,fee schedule,100% of bcbs custom fee schedule,0.52,100,,,fee schedule,100% of bcbs custom fee schedule,0.58,111,,,fee schedule,111% of bcbs custom fee schedule,801,50,,640.8,percent of total billed charges,50% of total billed charges,1121.4,70,,897.12,percent of total billed charges,70% of total billed charges,776.65,48.48,,621.32,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,776.65,48.48,,621.32,percent of total billed charges,48.48% of total billed charges,1121.4,70,,897.12,percent of total billed charges,70% of total billed charges,1121.4,70,,897.12,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,776.65,48.48,,621.32,percent of total billed charges,48.48% of total billed charges,1441.8,90,,1153.44,percent of total billed charges,90% of total billed charges,48.48,1441.8,
NOC^ PHENYLEPHRINE 1% SPR NAS,,,259,RC,J3490,HCPCS,outpatient,1,UN,18,10.80,,10.8,60,,8.64,percent of total billed charges,60% of total billed charges,8.64,48,,6.912,percent of total billed charges,48% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,12.6,70,,10.08,percent of total billed charges,70% of total billed charges,8.73,48.48,,6.984,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,8.73,48.48,,6.984,percent of total billed charges,48.48% of total billed charges,12.6,70,,10.08,percent of total billed charges,70% of total billed charges,12.6,70,,10.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,8.73,48.48,,6.984,percent of total billed charges,48.48% of total billed charges,16.2,90,,12.96,percent of total billed charges,90% of total billed charges,8.73,90,
NOC^ ESOMEPRAZOLE INJ 40 MG,,,250,RC,J3490,HCPCS,outpatient,1,UN,215,129.00,,129,60,,103.2,percent of total billed charges,60% of total billed charges,103.2,48,,82.56,percent of total billed charges,48% of total billed charges,107.5,50,,86,percent of total billed charges,50% of total billed charges,107.5,50,,86,percent of total billed charges,50% of total billed charges,107.5,50,,86,percent of total billed charges,50% of total billed charges,107.5,50,,86,percent of total billed charges,50% of total billed charges,150.5,70,,120.4,percent of total billed charges,70% of total billed charges,104.23,48.48,,83.384,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,104.23,48.48,,83.384,percent of total billed charges,48.48% of total billed charges,150.5,70,,120.4,percent of total billed charges,70% of total billed charges,150.5,70,,120.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,104.23,48.48,,83.384,percent of total billed charges,48.48% of total billed charges,193.5,90,,154.8,percent of total billed charges,90% of total billed charges,48.48,193.5,
NOC^ NEO/ POLY-B/GRM OIN [EYE],,,259,RC,J3490,HCPCS,outpatient,1,UN,246,147.60,,147.6,60,,118.08,percent of total billed charges,60% of total billed charges,118.08,48,,94.464,percent of total billed charges,48% of total billed charges,123,50,,98.4,percent of total billed charges,50% of total billed charges,123,50,,98.4,percent of total billed charges,50% of total billed charges,123,50,,98.4,percent of total billed charges,50% of total billed charges,123,50,,98.4,percent of total billed charges,50% of total billed charges,172.2,70,,137.76,percent of total billed charges,70% of total billed charges,119.26,48.48,,95.408,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,119.26,48.48,,95.408,percent of total billed charges,48.48% of total billed charges,172.2,70,,137.76,percent of total billed charges,70% of total billed charges,172.2,70,,137.76,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,119.26,48.48,,95.408,percent of total billed charges,48.48% of total billed charges,221.4,90,,177.12,percent of total billed charges,90% of total billed charges,48.48,221.4,
NOC^ NEOSYNEPH/XYLOC SPRY 10ML,,,259,RC,J3490,HCPCS,outpatient,1,UN,18,10.80,,10.8,60,,8.64,percent of total billed charges,60% of total billed charges,8.64,48,,6.912,percent of total billed charges,48% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,12.6,70,,10.08,percent of total billed charges,70% of total billed charges,8.73,48.48,,6.984,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,8.73,48.48,,6.984,percent of total billed charges,48.48% of total billed charges,12.6,70,,10.08,percent of total billed charges,70% of total billed charges,12.6,70,,10.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,8.73,48.48,,6.984,percent of total billed charges,48.48% of total billed charges,16.2,90,,12.96,percent of total billed charges,90% of total billed charges,8.73,90,
NOC^ ESOMEPRAZOLE CAP [40 MG),,,259,RC,J8499,HCPCS,outpatient,1,UN,32,19.20,,19.2,60,,15.36,percent of total billed charges,60% of total billed charges,15.36,48,,12.288,percent of total billed charges,48% of total billed charges,16,50,,12.8,percent of total billed charges,50% of total billed charges,16,50,,12.8,percent of total billed charges,50% of total billed charges,16,50,,12.8,percent of total billed charges,50% of total billed charges,16,50,,12.8,percent of total billed charges,50% of total billed charges,22.4,70,,17.92,percent of total billed charges,70% of total billed charges,15.51,48.48,,12.408,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,15.51,48.48,,12.408,percent of total billed charges,48.48% of total billed charges,22.4,70,,17.92,percent of total billed charges,70% of total billed charges,22.4,70,,17.92,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,15.51,48.48,,12.408,percent of total billed charges,48.48% of total billed charges,28.8,90,,23.04,percent of total billed charges,90% of total billed charges,15.51,90,
NOC^ KETOCONAZOLE TAB [200 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,13,7.80,,7.8,60,,6.24,percent of total billed charges,60% of total billed charges,6.24,48,,4.992,percent of total billed charges,48% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,9.1,70,,7.28,percent of total billed charges,70% of total billed charges,6.3,48.48,,5.04,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,6.3,48.48,,5.04,percent of total billed charges,48.48% of total billed charges,9.1,70,,7.28,percent of total billed charges,70% of total billed charges,9.1,70,,7.28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,6.3,48.48,,5.04,percent of total billed charges,48.48% of total billed charges,11.7,90,,9.36,percent of total billed charges,90% of total billed charges,6.3,90,
NOC^ CEFDINIR CAP 300 MG,,,259,RC,J8499,HCPCS,outpatient,1,UN,21,12.60,,12.6,60,,10.08,percent of total billed charges,60% of total billed charges,10.08,48,,8.064,percent of total billed charges,48% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,14.7,70,,11.76,percent of total billed charges,70% of total billed charges,10.18,48.48,,8.144,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,10.18,48.48,,8.144,percent of total billed charges,48.48% of total billed charges,14.7,70,,11.76,percent of total billed charges,70% of total billed charges,14.7,70,,11.76,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,10.18,48.48,,8.144,percent of total billed charges,48.48% of total billed charges,18.9,90,,15.12,percent of total billed charges,90% of total billed charges,10.18,90,
ORPHENADRINE INJ 60MG/2ML,43601519,CDM,250,RC,J2360,HCPCS,outpatient,1,UN,89,53.40,,53.4,60,,42.72,percent of total billed charges,60% of total billed charges,42.72,48,,34.176,percent of total billed charges,48% of total billed charges,5.82,100,,,fee schedule,100% of bcbs custom fee schedule,5.82,100,,,fee schedule,100% of bcbs custom fee schedule,6.46,111,,,fee schedule,111% of bcbs custom fee schedule,44.5,50,,35.6,percent of total billed charges,50% of total billed charges,62.3,70,,49.84,percent of total billed charges,70% of total billed charges,43.15,48.48,,34.52,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,43.15,48.48,,34.52,percent of total billed charges,48.48% of total billed charges,62.3,70,,49.84,percent of total billed charges,70% of total billed charges,62.3,70,,49.84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,43.15,48.48,,34.52,percent of total billed charges,48.48% of total billed charges,80.1,90,,64.08,percent of total billed charges,90% of total billed charges,43.15,90,
NALBUPHINE INJ [10 MG/ML],,,250,RC,J2300,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,3.38,100,,,fee schedule,100% of bcbs custom fee schedule,3.38,100,,,fee schedule,100% of bcbs custom fee schedule,3.75,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
"NOC^ NYSTATIN CRM [100,000 UNT",,,259,RC,J3490,HCPCS,outpatient,1,UN,70,42.00,,42,60,,33.6,percent of total billed charges,60% of total billed charges,33.6,48,,26.88,percent of total billed charges,48% of total billed charges,35,50,,28,percent of total billed charges,50% of total billed charges,35,50,,28,percent of total billed charges,50% of total billed charges,35,50,,28,percent of total billed charges,50% of total billed charges,35,50,,28,percent of total billed charges,50% of total billed charges,49,70,,39.2,percent of total billed charges,70% of total billed charges,33.94,48.48,,27.152,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,33.94,48.48,,27.152,percent of total billed charges,48.48% of total billed charges,49,70,,39.2,percent of total billed charges,70% of total billed charges,49,70,,39.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,33.94,48.48,,27.152,percent of total billed charges,48.48% of total billed charges,63,90,,50.4,percent of total billed charges,90% of total billed charges,33.94,90,
NOC^ MELOXICAM TAB [15 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
NOC^ METOPROLOL INJ [5 MG/5ML],,,250,RC,J3490,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
METHOTREXATE TAB [2.5 MG],,,250,RC,J8610,HCPCS,outpatient,1,UN,16,9.60,,9.6,60,,7.68,percent of total billed charges,60% of total billed charges,7.68,48,,6.144,percent of total billed charges,48% of total billed charges,0.17,100,,,fee schedule,100% of bcbs custom fee schedule,0.17,100,,,fee schedule,100% of bcbs custom fee schedule,0.19,111,,,fee schedule,111% of bcbs custom fee schedule,8,50,,6.4,percent of total billed charges,50% of total billed charges,11.2,70,,8.96,percent of total billed charges,70% of total billed charges,7.76,48.48,,6.208,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,7.76,48.48,,6.208,percent of total billed charges,48.48% of total billed charges,11.2,70,,8.96,percent of total billed charges,70% of total billed charges,11.2,70,,8.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,7.76,48.48,,6.208,percent of total billed charges,48.48% of total billed charges,14.4,90,,11.52,percent of total billed charges,90% of total billed charges,7.76,90,
NOC^ TELMISARTAN TAB [40 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,22,13.20,,13.2,60,,10.56,percent of total billed charges,60% of total billed charges,10.56,48,,8.448,percent of total billed charges,48% of total billed charges,11,50,,8.8,percent of total billed charges,50% of total billed charges,11,50,,8.8,percent of total billed charges,50% of total billed charges,11,50,,8.8,percent of total billed charges,50% of total billed charges,11,50,,8.8,percent of total billed charges,50% of total billed charges,15.4,70,,12.32,percent of total billed charges,70% of total billed charges,10.67,48.48,,8.536,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,10.67,48.48,,8.536,percent of total billed charges,48.48% of total billed charges,15.4,70,,12.32,percent of total billed charges,70% of total billed charges,15.4,70,,12.32,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,10.67,48.48,,8.536,percent of total billed charges,48.48% of total billed charges,19.8,90,,15.84,percent of total billed charges,90% of total billed charges,10.67,90,
NOC^ LUBRIDERM LOTION 6 OZ,,,259,RC,J3490,HCPCS,outpatient,1,UN,13,7.80,,7.8,60,,6.24,percent of total billed charges,60% of total billed charges,6.24,48,,4.992,percent of total billed charges,48% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,9.1,70,,7.28,percent of total billed charges,70% of total billed charges,6.3,48.48,,5.04,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,6.3,48.48,,5.04,percent of total billed charges,48.48% of total billed charges,9.1,70,,7.28,percent of total billed charges,70% of total billed charges,9.1,70,,7.28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,6.3,48.48,,5.04,percent of total billed charges,48.48% of total billed charges,11.7,90,,9.36,percent of total billed charges,90% of total billed charges,6.3,90,
NOC^ PREGABALIN CAP [75 MG),,,259,RC,J8499,HCPCS,outpatient,1,UN,14,8.40,,8.4,60,,6.72,percent of total billed charges,60% of total billed charges,6.72,48,,5.376,percent of total billed charges,48% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,9.8,70,,7.84,percent of total billed charges,70% of total billed charges,6.79,48.48,,5.432,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,6.79,48.48,,5.432,percent of total billed charges,48.48% of total billed charges,9.8,70,,7.84,percent of total billed charges,70% of total billed charges,9.8,70,,7.84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,6.79,48.48,,5.432,percent of total billed charges,48.48% of total billed charges,12.6,90,,10.08,percent of total billed charges,90% of total billed charges,6.79,90,
NOC^ PREGABALIN CAP [50 MG),,,259,RC,J8499,HCPCS,outpatient,1,UN,14,8.40,,8.4,60,,6.72,percent of total billed charges,60% of total billed charges,6.72,48,,5.376,percent of total billed charges,48% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,9.8,70,,7.84,percent of total billed charges,70% of total billed charges,6.79,48.48,,5.432,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,6.79,48.48,,5.432,percent of total billed charges,48.48% of total billed charges,9.8,70,,7.84,percent of total billed charges,70% of total billed charges,9.8,70,,7.84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,6.79,48.48,,5.432,percent of total billed charges,48.48% of total billed charges,12.6,90,,10.08,percent of total billed charges,90% of total billed charges,6.79,90,
NIACIN ER TAB [500 MG],,,257,RC,J8499,HCPCS,outpatient,1,UN,23,13.80,,13.8,60,,11.04,percent of total billed charges,60% of total billed charges,11.04,48,,8.832,percent of total billed charges,48% of total billed charges,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,16.1,70,,12.88,percent of total billed charges,70% of total billed charges,11.15,48.48,,8.92,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,11.15,48.48,,8.92,percent of total billed charges,48.48% of total billed charges,16.1,70,,12.88,percent of total billed charges,70% of total billed charges,16.1,70,,12.88,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,11.15,48.48,,8.92,percent of total billed charges,48.48% of total billed charges,20.7,90,,16.56,percent of total billed charges,90% of total billed charges,11.15,90,
NOC^ GEMFIBROZIL TAB [600 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,10,6.00,,6,60,,4.8,percent of total billed charges,60% of total billed charges,4.8,48,,3.84,percent of total billed charges,48% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,7,70,,5.6,percent of total billed charges,70% of total billed charges,4.85,48.48,,3.88,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,4.85,48.48,,3.88,percent of total billed charges,48.48% of total billed charges,7,70,,5.6,percent of total billed charges,70% of total billed charges,7,70,,5.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,4.85,48.48,,3.88,percent of total billed charges,48.48% of total billed charges,9,90,,7.2,percent of total billed charges,90% of total billed charges,4.85,90,
NORMAL SALINE VL 30CC,,,250,RC,,,outpatient,,,16.5,9.90,,9.9,60,,7.92,percent of total billed charges,60% of total billed charges,7.92,48,,6.336,percent of total billed charges,48% of total billed charges,8.25,50,,6.6,percent of total billed charges,50% of total billed charges,8.25,50,,6.6,percent of total billed charges,50% of total billed charges,8.25,50,,6.6,percent of total billed charges,50% of total billed charges,8.25,50,,6.6,percent of total billed charges,50% of total billed charges,11.55,70,,9.24,percent of total billed charges,70% of total billed charges,8,48.48,,6.4,percent of total billed charges,48.48% of total billed charges,8,48.48,,6.4,percent of total billed charges,48.48% of total billed charges,8,48.48,,6.4,percent of total billed charges,48.48% of total billed charges,11.55,70,,9.24,percent of total billed charges,70% of total billed charges,11.55,70,,9.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,8,48.48,,6.4,percent of total billed charges,48.48% of total billed charges,14.85,90,,11.88,percent of total billed charges,90% of total billed charges,8,90,
NOC^ NITROPRUSSIDE INJ [25 MG/,,,636,RC,J3490,HCPCS,outpatient,1,UN,1440,864.00,,864,60,,691.2,percent of total billed charges,60% of total billed charges,691.2,48,,552.96,percent of total billed charges,48% of total billed charges,720,50,,576,percent of total billed charges,50% of total billed charges,720,50,,576,percent of total billed charges,50% of total billed charges,720,50,,576,percent of total billed charges,50% of total billed charges,720,50,,576,percent of total billed charges,50% of total billed charges,1008,70,,806.4,percent of total billed charges,70% of total billed charges,698.11,48.48,,558.488,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,698.11,48.48,,558.488,percent of total billed charges,48.48% of total billed charges,1008,70,,806.4,percent of total billed charges,70% of total billed charges,1008,70,,806.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,698.11,48.48,,558.488,percent of total billed charges,48.48% of total billed charges,1296,90,,1036.8,percent of total billed charges,90% of total billed charges,48.48,1296,
NEOMYCIN-POLY-GRAM SOL 10,,,259,RC,,,outpatient,,,248,148.80,,148.8,60,,119.04,percent of total billed charges,60% of total billed charges,119.04,48,,95.232,percent of total billed charges,48% of total billed charges,124,50,,99.2,percent of total billed charges,50% of total billed charges,124,50,,99.2,percent of total billed charges,50% of total billed charges,124,50,,99.2,percent of total billed charges,50% of total billed charges,124,50,,99.2,percent of total billed charges,50% of total billed charges,173.6,70,,138.88,percent of total billed charges,70% of total billed charges,120.23,48.48,,96.184,percent of total billed charges,48.48% of total billed charges,120.23,48.48,,96.184,percent of total billed charges,48.48% of total billed charges,120.23,48.48,,96.184,percent of total billed charges,48.48% of total billed charges,173.6,70,,138.88,percent of total billed charges,70% of total billed charges,173.6,70,,138.88,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,120.23,48.48,,96.184,percent of total billed charges,48.48% of total billed charges,223.2,90,,178.56,percent of total billed charges,90% of total billed charges,48.48,223.2,
LEVOTHYROXINE INJ 100 MCG,,,250,RC,J3490,HCPCS,outpatient,1,UN,507,304.20,,304.2,60,,243.36,percent of total billed charges,60% of total billed charges,243.36,48,,194.688,percent of total billed charges,48% of total billed charges,253.5,50,,202.8,percent of total billed charges,50% of total billed charges,253.5,50,,202.8,percent of total billed charges,50% of total billed charges,253.5,50,,202.8,percent of total billed charges,50% of total billed charges,253.5,50,,202.8,percent of total billed charges,50% of total billed charges,354.9,70,,283.92,percent of total billed charges,70% of total billed charges,245.79,48.48,,196.632,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,245.79,48.48,,196.632,percent of total billed charges,48.48% of total billed charges,354.9,70,,283.92,percent of total billed charges,70% of total billed charges,354.9,70,,283.92,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,245.79,48.48,,196.632,percent of total billed charges,48.48% of total billed charges,456.3,90,,365.04,percent of total billed charges,90% of total billed charges,48.48,456.3,
NOC^ HETASTARCH/ NS INJ PREMIX,,,250,RC,J3490,HCPCS,outpatient,1,UN,82,49.20,,49.2,60,,39.36,percent of total billed charges,60% of total billed charges,39.36,48,,31.488,percent of total billed charges,48% of total billed charges,41,50,,32.8,percent of total billed charges,50% of total billed charges,41,50,,32.8,percent of total billed charges,50% of total billed charges,41,50,,32.8,percent of total billed charges,50% of total billed charges,41,50,,32.8,percent of total billed charges,50% of total billed charges,57.4,70,,45.92,percent of total billed charges,70% of total billed charges,39.75,48.48,,31.8,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,39.75,48.48,,31.8,percent of total billed charges,48.48% of total billed charges,57.4,70,,45.92,percent of total billed charges,70% of total billed charges,57.4,70,,45.92,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,39.75,48.48,,31.8,percent of total billed charges,48.48% of total billed charges,73.8,90,,59.04,percent of total billed charges,90% of total billed charges,39.75,90,
"NOC^ NYSTATIN OIN [100,000 UNT",,,259,RC,J3490,HCPCS,outpatient,1,UN,70,42.00,,42,60,,33.6,percent of total billed charges,60% of total billed charges,33.6,48,,26.88,percent of total billed charges,48% of total billed charges,35,50,,28,percent of total billed charges,50% of total billed charges,35,50,,28,percent of total billed charges,50% of total billed charges,35,50,,28,percent of total billed charges,50% of total billed charges,35,50,,28,percent of total billed charges,50% of total billed charges,49,70,,39.2,percent of total billed charges,70% of total billed charges,33.94,48.48,,27.152,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,33.94,48.48,,27.152,percent of total billed charges,48.48% of total billed charges,49,70,,39.2,percent of total billed charges,70% of total billed charges,49,70,,39.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,33.94,48.48,,27.152,percent of total billed charges,48.48% of total billed charges,63,90,,50.4,percent of total billed charges,90% of total billed charges,33.94,90,
PEDIALYTE SOL 8 OZ,,,257,RC,,,outpatient,,,12.1,7.26,,7.26,60,,5.808,percent of total billed charges,60% of total billed charges,5.81,48,,4.648,percent of total billed charges,48% of total billed charges,6.05,50,,4.84,percent of total billed charges,50% of total billed charges,6.05,50,,4.84,percent of total billed charges,50% of total billed charges,6.05,50,,4.84,percent of total billed charges,50% of total billed charges,6.05,50,,4.84,percent of total billed charges,50% of total billed charges,8.47,70,,6.776,percent of total billed charges,70% of total billed charges,5.87,48.48,,4.696,percent of total billed charges,48.48% of total billed charges,5.87,48.48,,4.696,percent of total billed charges,48.48% of total billed charges,5.87,48.48,,4.696,percent of total billed charges,48.48% of total billed charges,8.47,70,,6.776,percent of total billed charges,70% of total billed charges,8.47,70,,6.776,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,5.87,48.48,,4.696,percent of total billed charges,48.48% of total billed charges,10.89,90,,8.712,percent of total billed charges,90% of total billed charges,5.87,90,
NOC^ KETOCONAZOLE 2% CRM,,,259,RC,J3490,HCPCS,outpatient,1,UN,66,39.60,,39.6,60,,31.68,percent of total billed charges,60% of total billed charges,31.68,48,,25.344,percent of total billed charges,48% of total billed charges,33,50,,26.4,percent of total billed charges,50% of total billed charges,33,50,,26.4,percent of total billed charges,50% of total billed charges,33,50,,26.4,percent of total billed charges,50% of total billed charges,33,50,,26.4,percent of total billed charges,50% of total billed charges,46.2,70,,36.96,percent of total billed charges,70% of total billed charges,32,48.48,,25.6,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,32,48.48,,25.6,percent of total billed charges,48.48% of total billed charges,46.2,70,,36.96,percent of total billed charges,70% of total billed charges,46.2,70,,36.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,32,48.48,,25.6,percent of total billed charges,48.48% of total billed charges,59.4,90,,47.52,percent of total billed charges,90% of total billed charges,32,90,
NOC^ ZOLPIDEM TAB 10 MG,,,259,RC,J3490,HCPCS,outpatient,1,UN,19,11.40,,11.4,60,,9.12,percent of total billed charges,60% of total billed charges,9.12,48,,7.296,percent of total billed charges,48% of total billed charges,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,13.3,70,,10.64,percent of total billed charges,70% of total billed charges,9.21,48.48,,7.368,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.21,48.48,,7.368,percent of total billed charges,48.48% of total billed charges,13.3,70,,10.64,percent of total billed charges,70% of total billed charges,13.3,70,,10.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.21,48.48,,7.368,percent of total billed charges,48.48% of total billed charges,17.1,90,,13.68,percent of total billed charges,90% of total billed charges,9.21,90,
NOC^ AZELASTINE 0.05% DRP,,,259,RC,J3490,HCPCS,outpatient,1,UN,429,257.40,,257.4,60,,205.92,percent of total billed charges,60% of total billed charges,205.92,48,,164.736,percent of total billed charges,48% of total billed charges,214.5,50,,171.6,percent of total billed charges,50% of total billed charges,214.5,50,,171.6,percent of total billed charges,50% of total billed charges,214.5,50,,171.6,percent of total billed charges,50% of total billed charges,214.5,50,,171.6,percent of total billed charges,50% of total billed charges,300.3,70,,240.24,percent of total billed charges,70% of total billed charges,207.98,48.48,,166.384,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,207.98,48.48,,166.384,percent of total billed charges,48.48% of total billed charges,300.3,70,,240.24,percent of total billed charges,70% of total billed charges,300.3,70,,240.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,207.98,48.48,,166.384,percent of total billed charges,48.48% of total billed charges,386.1,90,,308.88,percent of total billed charges,90% of total billed charges,48.48,386.1,
NOC^ TRIAMCINOLONE INH,,,259,RC,J3490,HCPCS,outpatient,1,UN,77,46.20,,46.2,60,,36.96,percent of total billed charges,60% of total billed charges,36.96,48,,29.568,percent of total billed charges,48% of total billed charges,38.5,50,,30.8,percent of total billed charges,50% of total billed charges,38.5,50,,30.8,percent of total billed charges,50% of total billed charges,38.5,50,,30.8,percent of total billed charges,50% of total billed charges,38.5,50,,30.8,percent of total billed charges,50% of total billed charges,53.9,70,,43.12,percent of total billed charges,70% of total billed charges,37.33,48.48,,29.864,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,37.33,48.48,,29.864,percent of total billed charges,48.48% of total billed charges,53.9,70,,43.12,percent of total billed charges,70% of total billed charges,53.9,70,,43.12,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,37.33,48.48,,29.864,percent of total billed charges,48.48% of total billed charges,69.3,90,,55.44,percent of total billed charges,90% of total billed charges,37.33,90,
PROCAINAMIDE INJ [100 MG/,,,250,RC,J2690,HCPCS,outpatient,1,UN,42,25.20,,25.2,60,,20.16,percent of total billed charges,60% of total billed charges,20.16,48,,16.128,percent of total billed charges,48% of total billed charges,78.9,100,,,fee schedule,100% of bcbs custom fee schedule,78.9,100,,,fee schedule,100% of bcbs custom fee schedule,87.58,111,,,fee schedule,111% of bcbs custom fee schedule,21,50,,16.8,percent of total billed charges,50% of total billed charges,29.4,70,,23.52,percent of total billed charges,70% of total billed charges,20.36,48.48,,16.288,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,20.36,48.48,,16.288,percent of total billed charges,48.48% of total billed charges,29.4,70,,23.52,percent of total billed charges,70% of total billed charges,29.4,70,,23.52,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,20.36,48.48,,16.288,percent of total billed charges,48.48% of total billed charges,37.8,90,,30.24,percent of total billed charges,90% of total billed charges,20.36,90,
NOC^ PROPRANOLOL LA CAP [60 MG,,,259,RC,J8499,HCPCS,outpatient,1,UN,38,22.80,,22.8,60,,18.24,percent of total billed charges,60% of total billed charges,18.24,48,,14.592,percent of total billed charges,48% of total billed charges,19,50,,15.2,percent of total billed charges,50% of total billed charges,19,50,,15.2,percent of total billed charges,50% of total billed charges,19,50,,15.2,percent of total billed charges,50% of total billed charges,19,50,,15.2,percent of total billed charges,50% of total billed charges,26.6,70,,21.28,percent of total billed charges,70% of total billed charges,18.42,48.48,,14.736,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,18.42,48.48,,14.736,percent of total billed charges,48.48% of total billed charges,26.6,70,,21.28,percent of total billed charges,70% of total billed charges,26.6,70,,21.28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,18.42,48.48,,14.736,percent of total billed charges,48.48% of total billed charges,34.2,90,,27.36,percent of total billed charges,90% of total billed charges,18.42,90,
NOC^ POTASSIUM CL LIQ [20 MEQ/,,,259,RC,J3490,HCPCS,outpatient,1,UN,92,55.20,,55.2,60,,44.16,percent of total billed charges,60% of total billed charges,44.16,48,,35.328,percent of total billed charges,48% of total billed charges,46,50,,36.8,percent of total billed charges,50% of total billed charges,46,50,,36.8,percent of total billed charges,50% of total billed charges,46,50,,36.8,percent of total billed charges,50% of total billed charges,46,50,,36.8,percent of total billed charges,50% of total billed charges,64.4,70,,51.52,percent of total billed charges,70% of total billed charges,44.6,48.48,,35.68,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,44.6,48.48,,35.68,percent of total billed charges,48.48% of total billed charges,64.4,70,,51.52,percent of total billed charges,70% of total billed charges,64.4,70,,51.52,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,44.6,48.48,,35.68,percent of total billed charges,48.48% of total billed charges,82.8,90,,66.24,percent of total billed charges,90% of total billed charges,44.6,90,
DRONEDARONE TAB 400 MG,,,259,RC,J8499,HCPCS,outpatient,1,UN,56,33.60,,33.6,60,,26.88,percent of total billed charges,60% of total billed charges,26.88,48,,21.504,percent of total billed charges,48% of total billed charges,28,50,,22.4,percent of total billed charges,50% of total billed charges,28,50,,22.4,percent of total billed charges,50% of total billed charges,28,50,,22.4,percent of total billed charges,50% of total billed charges,28,50,,22.4,percent of total billed charges,50% of total billed charges,39.2,70,,31.36,percent of total billed charges,70% of total billed charges,27.15,48.48,,21.72,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,27.15,48.48,,21.72,percent of total billed charges,48.48% of total billed charges,39.2,70,,31.36,percent of total billed charges,70% of total billed charges,39.2,70,,31.36,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,27.15,48.48,,21.72,percent of total billed charges,48.48% of total billed charges,50.4,90,,40.32,percent of total billed charges,90% of total billed charges,27.15,90,
NOC^ HYDROXYCHLOROQUINE TAB [2,,,259,RC,J8499,HCPCS,outpatient,1,UN,18,10.80,,10.8,60,,8.64,percent of total billed charges,60% of total billed charges,8.64,48,,6.912,percent of total billed charges,48% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,12.6,70,,10.08,percent of total billed charges,70% of total billed charges,8.73,48.48,,6.984,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,8.73,48.48,,6.984,percent of total billed charges,48.48% of total billed charges,12.6,70,,10.08,percent of total billed charges,70% of total billed charges,12.6,70,,10.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,8.73,48.48,,6.984,percent of total billed charges,48.48% of total billed charges,16.2,90,,12.96,percent of total billed charges,90% of total billed charges,8.73,90,
NOC^ FENTANYL PAT [25 MCG/HR],,,250,RC,J3490,HCPCS,outpatient,1,UN,58,34.80,,34.8,60,,27.84,percent of total billed charges,60% of total billed charges,27.84,48,,22.272,percent of total billed charges,48% of total billed charges,29,50,,23.2,percent of total billed charges,50% of total billed charges,29,50,,23.2,percent of total billed charges,50% of total billed charges,29,50,,23.2,percent of total billed charges,50% of total billed charges,29,50,,23.2,percent of total billed charges,50% of total billed charges,40.6,70,,32.48,percent of total billed charges,70% of total billed charges,28.12,48.48,,22.496,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,28.12,48.48,,22.496,percent of total billed charges,48.48% of total billed charges,40.6,70,,32.48,percent of total billed charges,70% of total billed charges,40.6,70,,32.48,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,28.12,48.48,,22.496,percent of total billed charges,48.48% of total billed charges,52.2,90,,41.76,percent of total billed charges,90% of total billed charges,28.12,90,
FENTANYL PAT [75 MCG/HR],,,250,RC,J3490,HCPCS,outpatient,1,UN,161,96.60,,96.6,60,,77.28,percent of total billed charges,60% of total billed charges,77.28,48,,61.824,percent of total billed charges,48% of total billed charges,80.5,50,,64.4,percent of total billed charges,50% of total billed charges,80.5,50,,64.4,percent of total billed charges,50% of total billed charges,80.5,50,,64.4,percent of total billed charges,50% of total billed charges,80.5,50,,64.4,percent of total billed charges,50% of total billed charges,112.7,70,,90.16,percent of total billed charges,70% of total billed charges,78.05,48.48,,62.44,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,78.05,48.48,,62.44,percent of total billed charges,48.48% of total billed charges,112.7,70,,90.16,percent of total billed charges,70% of total billed charges,112.7,70,,90.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,78.05,48.48,,62.44,percent of total billed charges,48.48% of total billed charges,144.9,90,,115.92,percent of total billed charges,90% of total billed charges,48.48,144.9,
NOC^ CLOPIDOGREL TAB [75 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,28,16.80,,16.8,60,,13.44,percent of total billed charges,60% of total billed charges,13.44,48,,10.752,percent of total billed charges,48% of total billed charges,14,50,,11.2,percent of total billed charges,50% of total billed charges,14,50,,11.2,percent of total billed charges,50% of total billed charges,14,50,,11.2,percent of total billed charges,50% of total billed charges,14,50,,11.2,percent of total billed charges,50% of total billed charges,19.6,70,,15.68,percent of total billed charges,70% of total billed charges,13.57,48.48,,10.856,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,13.57,48.48,,10.856,percent of total billed charges,48.48% of total billed charges,19.6,70,,15.68,percent of total billed charges,70% of total billed charges,19.6,70,,15.68,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,13.57,48.48,,10.856,percent of total billed charges,48.48% of total billed charges,25.2,90,,20.16,percent of total billed charges,90% of total billed charges,13.57,90,
BISMUTH SUBSAL SUS 16 OZ,,,257,RC,A9150,HCPCS,outpatient,1,UN,13,7.80,,7.8,60,,6.24,percent of total billed charges,60% of total billed charges,6.24,48,,4.992,percent of total billed charges,48% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,9.1,70,,7.28,percent of total billed charges,70% of total billed charges,6.3,48.48,,5.04,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,6.3,48.48,,5.04,percent of total billed charges,48.48% of total billed charges,9.1,70,,7.28,percent of total billed charges,70% of total billed charges,9.1,70,,7.28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,6.3,48.48,,5.04,percent of total billed charges,48.48% of total billed charges,11.7,90,,9.36,percent of total billed charges,90% of total billed charges,6.3,90,
NOC^ PROMETHAZINE SUPP 12.5 MG,,,259,RC,J3490,HCPCS,outpatient,1,UN,71,42.60,,42.6,60,,34.08,percent of total billed charges,60% of total billed charges,34.08,48,,27.264,percent of total billed charges,48% of total billed charges,35.5,50,,28.4,percent of total billed charges,50% of total billed charges,35.5,50,,28.4,percent of total billed charges,50% of total billed charges,35.5,50,,28.4,percent of total billed charges,50% of total billed charges,35.5,50,,28.4,percent of total billed charges,50% of total billed charges,49.7,70,,39.76,percent of total billed charges,70% of total billed charges,34.42,48.48,,27.536,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,34.42,48.48,,27.536,percent of total billed charges,48.48% of total billed charges,49.7,70,,39.76,percent of total billed charges,70% of total billed charges,49.7,70,,39.76,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,34.42,48.48,,27.536,percent of total billed charges,48.48% of total billed charges,63.9,90,,51.12,percent of total billed charges,90% of total billed charges,34.42,90,
PROMETHAZINE INJ [25 MG/M,43601520,CDM,636,RC,J2550,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,2.54,100,,,fee schedule,100% of bcbs custom fee schedule,2.54,100,,,fee schedule,100% of bcbs custom fee schedule,2.82,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
PHENOBARBITAL INJ [130 MG,,,250,RC,J2560,HCPCS,outpatient,1,UN,299,179.40,,179.4,60,,143.52,percent of total billed charges,60% of total billed charges,143.52,48,,114.816,percent of total billed charges,48% of total billed charges,52.06,100,,,fee schedule,100% of bcbs custom fee schedule,52.06,100,,,fee schedule,100% of bcbs custom fee schedule,57.79,111,,,fee schedule,111% of bcbs custom fee schedule,149.5,50,,119.6,percent of total billed charges,50% of total billed charges,209.3,70,,167.44,percent of total billed charges,70% of total billed charges,144.96,48.48,,115.968,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,144.96,48.48,,115.968,percent of total billed charges,48.48% of total billed charges,209.3,70,,167.44,percent of total billed charges,70% of total billed charges,209.3,70,,167.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,144.96,48.48,,115.968,percent of total billed charges,48.48% of total billed charges,269.1,90,,215.28,percent of total billed charges,90% of total billed charges,48.48,269.1,
BUDESONIDE NEB [0.5 MG/2M,,,250,RC,J7626,HCPCS,outpatient,1,UN,51,30.60,,30.6,60,,24.48,percent of total billed charges,60% of total billed charges,24.48,48,,19.584,percent of total billed charges,48% of total billed charges,1.88,100,,,fee schedule,100% of bcbs custom fee schedule,1.88,100,,,fee schedule,100% of bcbs custom fee schedule,2.09,111,,,fee schedule,111% of bcbs custom fee schedule,25.5,50,,20.4,percent of total billed charges,50% of total billed charges,35.7,70,,28.56,percent of total billed charges,70% of total billed charges,24.72,48.48,,19.776,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,24.72,48.48,,19.776,percent of total billed charges,48.48% of total billed charges,35.7,70,,28.56,percent of total billed charges,70% of total billed charges,35.7,70,,28.56,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,24.72,48.48,,19.776,percent of total billed charges,48.48% of total billed charges,45.9,90,,36.72,percent of total billed charges,90% of total billed charges,24.72,90,
OXYTOCIN INJ [10 UNT/ML],,,250,RC,J2590,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,0.99,100,,,fee schedule,100% of bcbs custom fee schedule,0.99,100,,,fee schedule,100% of bcbs custom fee schedule,1.1,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
PNEUMOCOCCAL 23 INJ [0.5M,43601423,CDM,636,RC,90732,HCPCS,outpatient,1,UN,266,159.60,,159.6,60,,127.68,percent of total billed charges,60% of total billed charges,127.68,48,,102.144,percent of total billed charges,48% of total billed charges,131.91,100,,,fee schedule,100% of bcbs custom fee schedule,131.91,100,,,fee schedule,100% of bcbs custom fee schedule,146.42,111,,,fee schedule,111% of bcbs custom fee schedule,133,50,,106.4,percent of total billed charges,50% of total billed charges,186.2,70,,148.96,percent of total billed charges,70% of total billed charges,128.96,48.48,,103.168,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,128.96,48.48,,103.168,percent of total billed charges,48.48% of total billed charges,186.2,70,,148.96,percent of total billed charges,70% of total billed charges,186.2,70,,148.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,128.96,48.48,,103.168,percent of total billed charges,48.48% of total billed charges,239.4,90,,191.52,percent of total billed charges,90% of total billed charges,48.48,239.4,
POLIO VACCINE,43601418,CDM,250,RC,90713,HCPCS,outpatient,,,89,53.40,,53.4,60,,42.72,percent of total billed charges,60% of total billed charges,42.72,48,,34.176,percent of total billed charges,48% of total billed charges,39.95,100,,,fee schedule,100% of bcbs custom fee schedule,39.95,100,,,fee schedule,100% of bcbs custom fee schedule,44.34,111,,,fee schedule,111% of bcbs custom fee schedule,44.5,50,,35.6,percent of total billed charges,50% of total billed charges,62.3,70,,49.84,percent of total billed charges,70% of total billed charges,43.15,48.48,,34.52,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,43.15,48.48,,34.52,percent of total billed charges,48.48% of total billed charges,62.3,70,,49.84,percent of total billed charges,70% of total billed charges,62.3,70,,49.84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,43.15,48.48,,34.52,percent of total billed charges,48.48% of total billed charges,80.1,90,,64.08,percent of total billed charges,90% of total billed charges,43.15,90,
NOC^ TETRACAINE DRP 0.5% [EYE],,,259,RC,J3490,HCPCS,outpatient,1,UN,33,19.80,,19.8,60,,15.84,percent of total billed charges,60% of total billed charges,15.84,48,,12.672,percent of total billed charges,48% of total billed charges,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,23.1,70,,18.48,percent of total billed charges,70% of total billed charges,16,48.48,,12.8,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,16,48.48,,12.8,percent of total billed charges,48.48% of total billed charges,23.1,70,,18.48,percent of total billed charges,70% of total billed charges,23.1,70,,18.48,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,16,48.48,,12.8,percent of total billed charges,48.48% of total billed charges,29.7,90,,23.76,percent of total billed charges,90% of total billed charges,16,90,
POTASSIUM CL INJ 20MEQ/10,,,250,RC,J3480,HCPCS,outpatient,1,UN,22,13.20,,13.2,60,,10.56,percent of total billed charges,60% of total billed charges,10.56,48,,8.448,percent of total billed charges,48% of total billed charges,0.17,100,,,fee schedule,100% of bcbs custom fee schedule,0.17,100,,,fee schedule,100% of bcbs custom fee schedule,0.19,111,,,fee schedule,111% of bcbs custom fee schedule,11,50,,8.8,percent of total billed charges,50% of total billed charges,15.4,70,,12.32,percent of total billed charges,70% of total billed charges,10.67,48.48,,8.536,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,10.67,48.48,,8.536,percent of total billed charges,48.48% of total billed charges,15.4,70,,12.32,percent of total billed charges,70% of total billed charges,15.4,70,,12.32,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,10.67,48.48,,8.536,percent of total billed charges,48.48% of total billed charges,19.8,90,,15.84,percent of total billed charges,90% of total billed charges,10.67,90,
POT CHL 40MEQ VIAL,,,250,RC,J3480,HCPCS,outpatient,,,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,0.17,100,,,fee schedule,100% of bcbs custom fee schedule,0.17,100,,,fee schedule,100% of bcbs custom fee schedule,0.19,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
IMIPENEM/CILAS INJ 500 MG,,,636,RC,J0743,HCPCS,outpatient,1,UN,132,79.20,,79.2,60,,63.36,percent of total billed charges,60% of total billed charges,63.36,48,,50.688,percent of total billed charges,48% of total billed charges,6.96,100,,,fee schedule,100% of bcbs custom fee schedule,6.96,100,,,fee schedule,100% of bcbs custom fee schedule,7.73,111,,,fee schedule,111% of bcbs custom fee schedule,66,50,,52.8,percent of total billed charges,50% of total billed charges,92.4,70,,73.92,percent of total billed charges,70% of total billed charges,63.99,48.48,,51.192,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,63.99,48.48,,51.192,percent of total billed charges,48.48% of total billed charges,92.4,70,,73.92,percent of total billed charges,70% of total billed charges,92.4,70,,73.92,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,63.99,48.48,,51.192,percent of total billed charges,48.48% of total billed charges,118.8,90,,95.04,percent of total billed charges,90% of total billed charges,48.48,118.8,
PRANDIN TAB 2 mg,,,259,RC,,,outpatient,,,15,9.00,,9,60,,7.2,percent of total billed charges,60% of total billed charges,7.2,48,,5.76,percent of total billed charges,48% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,13.5,90,,10.8,percent of total billed charges,90% of total billed charges,7.27,90,
"PROCRIT 10,000 UNIT INJ",,,250,RC,J0885,HCPCS,outpatient,1,UN,1283,769.80,,769.8,60,,615.84,percent of total billed charges,60% of total billed charges,615.84,48,,492.672,percent of total billed charges,48% of total billed charges,9.47,100,,,fee schedule,100% of bcbs custom fee schedule,9.47,100,,,fee schedule,100% of bcbs custom fee schedule,10.51,111,,,fee schedule,111% of bcbs custom fee schedule,641.5,50,,513.2,percent of total billed charges,50% of total billed charges,898.1,70,,718.48,percent of total billed charges,70% of total billed charges,622,48.48,,497.6,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,622,48.48,,497.6,percent of total billed charges,48.48% of total billed charges,898.1,70,,718.48,percent of total billed charges,70% of total billed charges,898.1,70,,718.48,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,622,48.48,,497.6,percent of total billed charges,48.48% of total billed charges,1154.7,90,,923.76,percent of total billed charges,90% of total billed charges,48.48,1154.7,
NOC^ PANTOPRAZOLE TAB [40 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,31,18.60,,18.6,60,,14.88,percent of total billed charges,60% of total billed charges,14.88,48,,11.904,percent of total billed charges,48% of total billed charges,15.5,50,,12.4,percent of total billed charges,50% of total billed charges,15.5,50,,12.4,percent of total billed charges,50% of total billed charges,15.5,50,,12.4,percent of total billed charges,50% of total billed charges,15.5,50,,12.4,percent of total billed charges,50% of total billed charges,21.7,70,,17.36,percent of total billed charges,70% of total billed charges,15.03,48.48,,12.024,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,15.03,48.48,,12.024,percent of total billed charges,48.48% of total billed charges,21.7,70,,17.36,percent of total billed charges,70% of total billed charges,21.7,70,,17.36,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,15.03,48.48,,12.024,percent of total billed charges,48.48% of total billed charges,27.9,90,,22.32,percent of total billed charges,90% of total billed charges,15.03,90,
PANTOPRAZOLE INJ 40 MG,,,250,RC,J2470,HCPCS,outpatient,1,UN,34,20.40,,20.4,60,,16.32,percent of total billed charges,60% of total billed charges,16.32,48,,13.056,percent of total billed charges,48% of total billed charges,17,50,,13.6,percent of total billed charges,50% of total billed charges,17,50,,13.6,percent of total billed charges,50% of total billed charges,17,50,,13.6,percent of total billed charges,50% of total billed charges,17,50,,13.6,percent of total billed charges,50% of total billed charges,23.8,70,,19.04,percent of total billed charges,70% of total billed charges,16.48,48.48,,13.184,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,16.48,48.48,,13.184,percent of total billed charges,48.48% of total billed charges,23.8,70,,19.04,percent of total billed charges,70% of total billed charges,23.8,70,,19.04,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,16.48,48.48,,13.184,percent of total billed charges,48.48% of total billed charges,30.6,90,,24.48,percent of total billed charges,90% of total billed charges,16.48,90,
PROTAMINE SULF INJ [250MG,,,250,RC,J2720,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,1.19,100,,,fee schedule,100% of bcbs custom fee schedule,1.19,100,,,fee schedule,100% of bcbs custom fee schedule,1.32,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
MODAFINIL TAB [200 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,142,85.20,,85.2,60,,68.16,percent of total billed charges,60% of total billed charges,68.16,48,,54.528,percent of total billed charges,48% of total billed charges,71,50,,56.8,percent of total billed charges,50% of total billed charges,71,50,,56.8,percent of total billed charges,50% of total billed charges,71,50,,56.8,percent of total billed charges,50% of total billed charges,71,50,,56.8,percent of total billed charges,50% of total billed charges,99.4,70,,79.52,percent of total billed charges,70% of total billed charges,68.84,48.48,,55.072,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,68.84,48.48,,55.072,percent of total billed charges,48.48% of total billed charges,99.4,70,,79.52,percent of total billed charges,70% of total billed charges,99.4,70,,79.52,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,68.84,48.48,,55.072,percent of total billed charges,48.48% of total billed charges,127.8,90,,102.24,percent of total billed charges,90% of total billed charges,48.48,127.8,
ALBUTEROL MDI,,,250,RC,J3535,HCPCS,outpatient,1,UN,322,193.20,,193.2,60,,154.56,percent of total billed charges,60% of total billed charges,154.56,48,,123.648,percent of total billed charges,48% of total billed charges,161,50,,128.8,percent of total billed charges,50% of total billed charges,161,50,,128.8,percent of total billed charges,50% of total billed charges,161,50,,128.8,percent of total billed charges,50% of total billed charges,161,50,,128.8,percent of total billed charges,50% of total billed charges,225.4,70,,180.32,percent of total billed charges,70% of total billed charges,156.11,48.48,,124.888,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,156.11,48.48,,124.888,percent of total billed charges,48.48% of total billed charges,225.4,70,,180.32,percent of total billed charges,70% of total billed charges,225.4,70,,180.32,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,156.11,48.48,,124.888,percent of total billed charges,48.48% of total billed charges,289.8,90,,231.84,percent of total billed charges,90% of total billed charges,48.48,289.8,
PHENAZOPYRIDINE TAB [200,,,251,RC,J8499,HCPCS,outpatient,1,UN,16,9.60,,9.6,60,,7.68,percent of total billed charges,60% of total billed charges,7.68,48,,6.144,percent of total billed charges,48% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,11.2,70,,8.96,percent of total billed charges,70% of total billed charges,7.76,48.48,,6.208,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,7.76,48.48,,6.208,percent of total billed charges,48.48% of total billed charges,11.2,70,,8.96,percent of total billed charges,70% of total billed charges,11.2,70,,8.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,7.76,48.48,,6.208,percent of total billed charges,48.48% of total billed charges,14.4,90,,11.52,percent of total billed charges,90% of total billed charges,7.76,90,
NOC^ NIFEDIPINE ER TAB [60 MG],,,259,RC,J3490,HCPCS,outpatient,1,UN,10,6.00,,6,60,,4.8,percent of total billed charges,60% of total billed charges,4.8,48,,3.84,percent of total billed charges,48% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,7,70,,5.6,percent of total billed charges,70% of total billed charges,4.85,48.48,,3.88,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,4.85,48.48,,3.88,percent of total billed charges,48.48% of total billed charges,7,70,,5.6,percent of total billed charges,70% of total billed charges,7,70,,5.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,4.85,48.48,,3.88,percent of total billed charges,48.48% of total billed charges,9,90,,7.2,percent of total billed charges,90% of total billed charges,4.85,90,
NOC^ FLUOXETINE CAP [10 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,11,6.60,,6.6,60,,5.28,percent of total billed charges,60% of total billed charges,5.28,48,,4.224,percent of total billed charges,48% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,9.9,90,,7.92,percent of total billed charges,90% of total billed charges,5.33,90,
NOC^ POTASSIUM PHOS INJ 45MM/1,,,250,RC,J3490,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
NOC^ FLUOXETINE CAP [20 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,11,6.60,,6.6,60,,5.28,percent of total billed charges,60% of total billed charges,5.28,48,,4.224,percent of total billed charges,48% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,9.9,90,,7.92,percent of total billed charges,90% of total billed charges,5.33,90,
NOC^ CHOLESTYRAMINE PKT [4 GM],,,259,RC,J3490,HCPCS,outpatient,1,UN,21,12.60,,12.6,60,,10.08,percent of total billed charges,60% of total billed charges,10.08,48,,8.064,percent of total billed charges,48% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,14.7,70,,11.76,percent of total billed charges,70% of total billed charges,10.18,48.48,,8.144,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,10.18,48.48,,8.144,percent of total billed charges,48.48% of total billed charges,14.7,70,,11.76,percent of total billed charges,70% of total billed charges,14.7,70,,11.76,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,10.18,48.48,,8.144,percent of total billed charges,48.48% of total billed charges,18.9,90,,15.12,percent of total billed charges,90% of total billed charges,10.18,90,
NOC^ QVAR INHALER 80 MCG,,,250,RC,J3490,HCPCS,outpatient,1,UN,1284,770.40,,770.4,60,,616.32,percent of total billed charges,60% of total billed charges,616.32,48,,493.056,percent of total billed charges,48% of total billed charges,642,50,,513.6,percent of total billed charges,50% of total billed charges,642,50,,513.6,percent of total billed charges,50% of total billed charges,642,50,,513.6,percent of total billed charges,50% of total billed charges,642,50,,513.6,percent of total billed charges,50% of total billed charges,898.8,70,,719.04,percent of total billed charges,70% of total billed charges,622.48,48.48,,497.984,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,622.48,48.48,,497.984,percent of total billed charges,48.48% of total billed charges,898.8,70,,719.04,percent of total billed charges,70% of total billed charges,898.8,70,,719.04,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,622.48,48.48,,497.984,percent of total billed charges,48.48% of total billed charges,1155.6,90,,924.48,percent of total billed charges,90% of total billed charges,48.48,1155.6,
REPAGLINIDE TAB [1 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,15,9.00,,9,60,,7.2,percent of total billed charges,60% of total billed charges,7.2,48,,5.76,percent of total billed charges,48% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,13.5,90,,10.8,percent of total billed charges,90% of total billed charges,7.27,90,
PROMETHAZINE INJ [50 MG/M,43601520,CDM,250,RC,J2550,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,2.54,100,,,fee schedule,100% of bcbs custom fee schedule,2.54,100,,,fee schedule,100% of bcbs custom fee schedule,2.82,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
NOC^ PREDNISOLONE 1% DRP [EYE],,,259,RC,J8499,HCPCS,outpatient,1,UN,51,30.60,,30.6,60,,24.48,percent of total billed charges,60% of total billed charges,24.48,48,,19.584,percent of total billed charges,48% of total billed charges,25.5,50,,20.4,percent of total billed charges,50% of total billed charges,25.5,50,,20.4,percent of total billed charges,50% of total billed charges,25.5,50,,20.4,percent of total billed charges,50% of total billed charges,25.5,50,,20.4,percent of total billed charges,50% of total billed charges,35.7,70,,28.56,percent of total billed charges,70% of total billed charges,24.72,48.48,,19.776,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,24.72,48.48,,19.776,percent of total billed charges,48.48% of total billed charges,35.7,70,,28.56,percent of total billed charges,70% of total billed charges,35.7,70,,28.56,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,24.72,48.48,,19.776,percent of total billed charges,48.48% of total billed charges,45.9,90,,36.72,percent of total billed charges,90% of total billed charges,24.72,90,
NOC^ OLOPATADINE 0.1% DRP [EYE,,,259,RC,J3490,HCPCS,outpatient,1,UN,1078,646.80,,646.8,60,,517.44,percent of total billed charges,60% of total billed charges,517.44,48,,413.952,percent of total billed charges,48% of total billed charges,539,50,,431.2,percent of total billed charges,50% of total billed charges,539,50,,431.2,percent of total billed charges,50% of total billed charges,539,50,,431.2,percent of total billed charges,50% of total billed charges,539,50,,431.2,percent of total billed charges,50% of total billed charges,754.6,70,,603.68,percent of total billed charges,70% of total billed charges,522.61,48.48,,418.088,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,522.61,48.48,,418.088,percent of total billed charges,48.48% of total billed charges,754.6,70,,603.68,percent of total billed charges,70% of total billed charges,754.6,70,,603.68,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,522.61,48.48,,418.088,percent of total billed charges,48.48% of total billed charges,970.2,90,,776.16,percent of total billed charges,90% of total billed charges,48.48,970.2,
NOC^ OMEPRAZOLE CAP [20 MG,,,259,RC,J8499,HCPCS,outpatient,1,UN,16,9.60,,9.6,60,,7.68,percent of total billed charges,60% of total billed charges,7.68,48,,6.144,percent of total billed charges,48% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,11.2,70,,8.96,percent of total billed charges,70% of total billed charges,7.76,48.48,,6.208,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,7.76,48.48,,6.208,percent of total billed charges,48.48% of total billed charges,11.2,70,,8.96,percent of total billed charges,70% of total billed charges,11.2,70,,8.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,7.76,48.48,,6.208,percent of total billed charges,48.48% of total billed charges,14.4,90,,11.52,percent of total billed charges,90% of total billed charges,7.76,90,
DESVENLAFAXINE TAB 50 MG,,,259,RC,J8499,HCPCS,outpatient,1,UN,26,15.60,,15.6,60,,12.48,percent of total billed charges,60% of total billed charges,12.48,48,,9.984,percent of total billed charges,48% of total billed charges,13,50,,10.4,percent of total billed charges,50% of total billed charges,13,50,,10.4,percent of total billed charges,50% of total billed charges,13,50,,10.4,percent of total billed charges,50% of total billed charges,13,50,,10.4,percent of total billed charges,50% of total billed charges,18.2,70,,14.56,percent of total billed charges,70% of total billed charges,12.6,48.48,,10.08,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,12.6,48.48,,10.08,percent of total billed charges,48.48% of total billed charges,18.2,70,,14.56,percent of total billed charges,70% of total billed charges,18.2,70,,14.56,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,12.6,48.48,,10.08,percent of total billed charges,48.48% of total billed charges,23.4,90,,18.72,percent of total billed charges,90% of total billed charges,12.6,90,
IMIPENEM/CILAS INJ 250 MG,,,250,RC,J0743,HCPCS,outpatient,1,UN,66,39.60,,39.6,60,,31.68,percent of total billed charges,60% of total billed charges,31.68,48,,25.344,percent of total billed charges,48% of total billed charges,6.96,100,,,fee schedule,100% of bcbs custom fee schedule,6.96,100,,,fee schedule,100% of bcbs custom fee schedule,7.73,111,,,fee schedule,111% of bcbs custom fee schedule,33,50,,26.4,percent of total billed charges,50% of total billed charges,46.2,70,,36.96,percent of total billed charges,70% of total billed charges,32,48.48,,25.6,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,32,48.48,,25.6,percent of total billed charges,48.48% of total billed charges,46.2,70,,36.96,percent of total billed charges,70% of total billed charges,46.2,70,,36.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,32,48.48,,25.6,percent of total billed charges,48.48% of total billed charges,59.4,90,,47.52,percent of total billed charges,90% of total billed charges,32,90,
NOC^ PILOCARPINE 1% [EYE],,,259,RC,J3490,HCPCS,outpatient,1,UN,124,74.40,,74.4,60,,59.52,percent of total billed charges,60% of total billed charges,59.52,48,,47.616,percent of total billed charges,48% of total billed charges,62,50,,49.6,percent of total billed charges,50% of total billed charges,62,50,,49.6,percent of total billed charges,50% of total billed charges,62,50,,49.6,percent of total billed charges,50% of total billed charges,62,50,,49.6,percent of total billed charges,50% of total billed charges,86.8,70,,69.44,percent of total billed charges,70% of total billed charges,60.12,48.48,,48.096,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,60.12,48.48,,48.096,percent of total billed charges,48.48% of total billed charges,86.8,70,,69.44,percent of total billed charges,70% of total billed charges,86.8,70,,69.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,60.12,48.48,,48.096,percent of total billed charges,48.48% of total billed charges,111.6,90,,89.28,percent of total billed charges,90% of total billed charges,48.48,111.6,
"NOC^ NYSTATIN PWD [100,000 UNT",,,259,RC,J3490,HCPCS,outpatient,1,UN,110,66.00,,66,60,,52.8,percent of total billed charges,60% of total billed charges,52.8,48,,42.24,percent of total billed charges,48% of total billed charges,55,50,,44,percent of total billed charges,50% of total billed charges,55,50,,44,percent of total billed charges,50% of total billed charges,55,50,,44,percent of total billed charges,50% of total billed charges,55,50,,44,percent of total billed charges,50% of total billed charges,77,70,,61.6,percent of total billed charges,70% of total billed charges,53.33,48.48,,42.664,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,53.33,48.48,,42.664,percent of total billed charges,48.48% of total billed charges,77,70,,61.6,percent of total billed charges,70% of total billed charges,77,70,,61.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,53.33,48.48,,42.664,percent of total billed charges,48.48% of total billed charges,99,90,,79.2,percent of total billed charges,90% of total billed charges,48.48,99,
ZOLEDRONIC ACID IVPB 5 MG (RECLAST),,,636,RC,J3489,HCPCS,outpatient,1,UN,1440,864.00,,864,60,,691.2,percent of total billed charges,60% of total billed charges,691.2,48,,552.96,percent of total billed charges,48% of total billed charges,10.68,100,,,fee schedule,100% of bcbs custom fee schedule,10.68,100,,,fee schedule,100% of bcbs custom fee schedule,11.85,111,,,fee schedule,111% of bcbs custom fee schedule,720,50,,576,percent of total billed charges,50% of total billed charges,1008,70,,806.4,percent of total billed charges,70% of total billed charges,698.11,48.48,,558.488,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,698.11,48.48,,558.488,percent of total billed charges,48.48% of total billed charges,1008,70,,806.4,percent of total billed charges,70% of total billed charges,1008,70,,806.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,698.11,48.48,,558.488,percent of total billed charges,48.48% of total billed charges,1296,90,,1036.8,percent of total billed charges,90% of total billed charges,48.48,1296,
REFRESH TEARS OPT SOL,,,250,RC,,,outpatient,,,40,24.00,,24,60,,19.2,percent of total billed charges,60% of total billed charges,19.2,48,,15.36,percent of total billed charges,48% of total billed charges,20,50,,16,percent of total billed charges,50% of total billed charges,20,50,,16,percent of total billed charges,50% of total billed charges,20,50,,16,percent of total billed charges,50% of total billed charges,20,50,,16,percent of total billed charges,50% of total billed charges,28,70,,22.4,percent of total billed charges,70% of total billed charges,19.39,48.48,,15.512,percent of total billed charges,48.48% of total billed charges,19.39,48.48,,15.512,percent of total billed charges,48.48% of total billed charges,19.39,48.48,,15.512,percent of total billed charges,48.48% of total billed charges,28,70,,22.4,percent of total billed charges,70% of total billed charges,28,70,,22.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,19.39,48.48,,15.512,percent of total billed charges,48.48% of total billed charges,36,90,,28.8,percent of total billed charges,90% of total billed charges,19.39,90,
NOC^ LANSOPRAZOLE CAP [30 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,23,13.80,,13.8,60,,11.04,percent of total billed charges,60% of total billed charges,11.04,48,,8.832,percent of total billed charges,48% of total billed charges,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,16.1,70,,12.88,percent of total billed charges,70% of total billed charges,11.15,48.48,,8.92,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,11.15,48.48,,8.92,percent of total billed charges,48.48% of total billed charges,16.1,70,,12.88,percent of total billed charges,70% of total billed charges,16.1,70,,12.88,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,11.15,48.48,,8.92,percent of total billed charges,48.48% of total billed charges,20.7,90,,16.56,percent of total billed charges,90% of total billed charges,11.15,90,
NOC^ LANSOPRAZOLE SOLUTAB [30,,,259,RC,J8499,HCPCS,outpatient,1,UN,64,38.40,,38.4,60,,30.72,percent of total billed charges,60% of total billed charges,30.72,48,,24.576,percent of total billed charges,48% of total billed charges,32,50,,25.6,percent of total billed charges,50% of total billed charges,32,50,,25.6,percent of total billed charges,50% of total billed charges,32,50,,25.6,percent of total billed charges,50% of total billed charges,32,50,,25.6,percent of total billed charges,50% of total billed charges,44.8,70,,35.84,percent of total billed charges,70% of total billed charges,31.03,48.48,,24.824,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,31.03,48.48,,24.824,percent of total billed charges,48.48% of total billed charges,44.8,70,,35.84,percent of total billed charges,70% of total billed charges,44.8,70,,35.84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,31.03,48.48,,24.824,percent of total billed charges,48.48% of total billed charges,57.6,90,,46.08,percent of total billed charges,90% of total billed charges,31.03,90,
NOC^ LANSOPRAZOLE SOLUTAB [15,,,259,RC,J3490,HCPCS,outpatient,1,UN,67,40.20,,40.2,60,,32.16,percent of total billed charges,60% of total billed charges,32.16,48,,25.728,percent of total billed charges,48% of total billed charges,33.5,50,,26.8,percent of total billed charges,50% of total billed charges,33.5,50,,26.8,percent of total billed charges,50% of total billed charges,33.5,50,,26.8,percent of total billed charges,50% of total billed charges,33.5,50,,26.8,percent of total billed charges,50% of total billed charges,46.9,70,,37.52,percent of total billed charges,70% of total billed charges,32.48,48.48,,25.984,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,32.48,48.48,,25.984,percent of total billed charges,48.48% of total billed charges,46.9,70,,37.52,percent of total billed charges,70% of total billed charges,46.9,70,,37.52,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,32.48,48.48,,25.984,percent of total billed charges,48.48% of total billed charges,60.3,90,,48.24,percent of total billed charges,90% of total billed charges,32.48,90,
MORPHINE INJ [4 MG/ML],43601516,CDM,250,RC,J2270,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,2.06,100,,,fee schedule,100% of bcbs custom fee schedule,2.06,100,,,fee schedule,100% of bcbs custom fee schedule,2.29,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
REMICADE INJ 100 MG,,,636,RC,J1745,HCPCS,outpatient,10,UN,2803,1681.80,,1681.8,60,,1345.44,percent of total billed charges,60% of total billed charges,1345.44,48,,1076.352,percent of total billed charges,48% of total billed charges,52.38,100,,,fee schedule,100% of bcbs custom fee schedule,52.38,100,,,fee schedule,100% of bcbs custom fee schedule,58.14,111,,,fee schedule,111% of bcbs custom fee schedule,1401.5,50,,1121.2,percent of total billed charges,50% of total billed charges,1962.1,70,,1569.68,percent of total billed charges,70% of total billed charges,1358.89,48.48,,1087.112,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,1358.89,48.48,,1087.112,percent of total billed charges,48.48% of total billed charges,1962.1,70,,1569.68,percent of total billed charges,70% of total billed charges,1962.1,70,,1569.68,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,1358.89,48.48,,1087.112,percent of total billed charges,48.48% of total billed charges,2522.7,90,,2018.16,percent of total billed charges,90% of total billed charges,48.48,2522.7,
NOC^ MIRTAZAPINE TAB [15 MG],,,259,RC,J3490,HCPCS,outpatient,1,UN,11,6.60,,6.6,60,,5.28,percent of total billed charges,60% of total billed charges,5.28,48,,4.224,percent of total billed charges,48% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,9.9,90,,7.92,percent of total billed charges,90% of total billed charges,5.33,90,
NOC^ PHNYL/ MO/ SHLVO/ PET OIN,,,257,RC,J3490,HCPCS,outpatient,1,UN,27,16.20,,16.2,60,,12.96,percent of total billed charges,60% of total billed charges,12.96,48,,10.368,percent of total billed charges,48% of total billed charges,13.5,50,,10.8,percent of total billed charges,50% of total billed charges,13.5,50,,10.8,percent of total billed charges,50% of total billed charges,13.5,50,,10.8,percent of total billed charges,50% of total billed charges,13.5,50,,10.8,percent of total billed charges,50% of total billed charges,18.9,70,,15.12,percent of total billed charges,70% of total billed charges,13.09,48.48,,10.472,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,13.09,48.48,,10.472,percent of total billed charges,48.48% of total billed charges,18.9,70,,15.12,percent of total billed charges,70% of total billed charges,18.9,70,,15.12,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,13.09,48.48,,10.472,percent of total billed charges,48.48% of total billed charges,24.3,90,,19.44,percent of total billed charges,90% of total billed charges,13.09,90,
TERCONAZOLE 0.8% VAG CRM,,,259,RC,J3490,HCPCS,outpatient,1,UN,220,132.00,,132,60,,105.6,percent of total billed charges,60% of total billed charges,105.6,48,,84.48,percent of total billed charges,48% of total billed charges,110,50,,88,percent of total billed charges,50% of total billed charges,110,50,,88,percent of total billed charges,50% of total billed charges,110,50,,88,percent of total billed charges,50% of total billed charges,110,50,,88,percent of total billed charges,50% of total billed charges,154,70,,123.2,percent of total billed charges,70% of total billed charges,106.66,48.48,,85.328,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,106.66,48.48,,85.328,percent of total billed charges,48.48% of total billed charges,154,70,,123.2,percent of total billed charges,70% of total billed charges,154,70,,123.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,106.66,48.48,,85.328,percent of total billed charges,48.48% of total billed charges,198,90,,158.4,percent of total billed charges,90% of total billed charges,48.48,198,
NOC^ PROPAFENONE TAB 150 MG,,,259,RC,J8499,HCPCS,outpatient,1,UN,19,11.40,,11.4,60,,9.12,percent of total billed charges,60% of total billed charges,9.12,48,,7.296,percent of total billed charges,48% of total billed charges,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,13.3,70,,10.64,percent of total billed charges,70% of total billed charges,9.21,48.48,,7.368,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.21,48.48,,7.368,percent of total billed charges,48.48% of total billed charges,13.3,70,,10.64,percent of total billed charges,70% of total billed charges,13.3,70,,10.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.21,48.48,,7.368,percent of total billed charges,48.48% of total billed charges,17.1,90,,13.68,percent of total billed charges,90% of total billed charges,9.21,90,
SUCCINYLCHOLINE INJ [20 M,,,250,RC,J0330,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,2.19,100,,,fee schedule,100% of bcbs custom fee schedule,2.19,100,,,fee schedule,100% of bcbs custom fee schedule,2.43,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
NOC^ RISPERIDONE TAB [1 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,19,11.40,,11.4,60,,9.12,percent of total billed charges,60% of total billed charges,9.12,48,,7.296,percent of total billed charges,48% of total billed charges,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,13.3,70,,10.64,percent of total billed charges,70% of total billed charges,9.21,48.48,,7.368,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.21,48.48,,7.368,percent of total billed charges,48.48% of total billed charges,13.3,70,,10.64,percent of total billed charges,70% of total billed charges,13.3,70,,10.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.21,48.48,,7.368,percent of total billed charges,48.48% of total billed charges,17.1,90,,13.68,percent of total billed charges,90% of total billed charges,9.21,90,
RABIES VACCINE 1 ML,,,636,RC,90675,HCPCS,outpatient,1,ML,867,520.20,,520.2,60,,416.16,percent of total billed charges,60% of total billed charges,416.16,48,,332.928,percent of total billed charges,48% of total billed charges,333.56,100,,,fee schedule,100% of bcbs custom fee schedule,333.56,100,,,fee schedule,100% of bcbs custom fee schedule,370.25,111,,,fee schedule,111% of bcbs custom fee schedule,433.5,50,,346.8,percent of total billed charges,50% of total billed charges,606.9,70,,485.52,percent of total billed charges,70% of total billed charges,420.32,48.48,,336.256,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,420.32,48.48,,336.256,percent of total billed charges,48.48% of total billed charges,606.9,70,,485.52,percent of total billed charges,70% of total billed charges,606.9,70,,485.52,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,420.32,48.48,,336.256,percent of total billed charges,48.48% of total billed charges,780.3,90,,624.24,percent of total billed charges,90% of total billed charges,48.48,780.3,
NOC^ CYCLOSPORINE DRP,,,259,RC,J3490,HCPCS,outpatient,1,UN,18,10.80,,10.8,60,,8.64,percent of total billed charges,60% of total billed charges,8.64,48,,6.912,percent of total billed charges,48% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,12.6,70,,10.08,percent of total billed charges,70% of total billed charges,8.73,48.48,,6.984,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,8.73,48.48,,6.984,percent of total billed charges,48.48% of total billed charges,12.6,70,,10.08,percent of total billed charges,70% of total billed charges,12.6,70,,10.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,8.73,48.48,,6.984,percent of total billed charges,48.48% of total billed charges,16.2,90,,12.96,percent of total billed charges,90% of total billed charges,8.73,90,
METOCLOPRAMIDE INJ 5MG/ML,43601521,CDM,250,RC,J2765,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,1.14,100,,,fee schedule,100% of bcbs custom fee schedule,1.14,100,,,fee schedule,100% of bcbs custom fee schedule,1.27,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
NOC^ ROPINIROLE TAB [0.25 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,15,9.00,,9,60,,7.2,percent of total billed charges,60% of total billed charges,7.2,48,,5.76,percent of total billed charges,48% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,13.5,90,,10.8,percent of total billed charges,90% of total billed charges,7.27,90,
NOC^ ROPINIROLE TAB [0.5 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,15,9.00,,9,60,,7.2,percent of total billed charges,60% of total billed charges,7.2,48,,5.76,percent of total billed charges,48% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,13.5,90,,10.8,percent of total billed charges,90% of total billed charges,7.27,90,
NOC^ MIRTAZAPINE TAB [30 MG],,,259,RC,J3490,HCPCS,outpatient,1,UN,12,7.20,,7.2,60,,5.76,percent of total billed charges,60% of total billed charges,5.76,48,,4.608,percent of total billed charges,48% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,8.4,70,,6.72,percent of total billed charges,70% of total billed charges,5.82,48.48,,4.656,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,5.82,48.48,,4.656,percent of total billed charges,48.48% of total billed charges,8.4,70,,6.72,percent of total billed charges,70% of total billed charges,8.4,70,,6.72,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,5.82,48.48,,4.656,percent of total billed charges,48.48% of total billed charges,10.8,90,,8.64,percent of total billed charges,90% of total billed charges,5.82,90,
CEFTRIAXONE INJ 1 GM,43601503,CDM,636,RC,J0696,HCPCS,outpatient,4,UN,80,48.00,,48,60,,38.4,percent of total billed charges,60% of total billed charges,38.4,48,,30.72,percent of total billed charges,48% of total billed charges,0.69,100,,,fee schedule,100% of bcbs custom fee schedule,0.69,100,,,fee schedule,100% of bcbs custom fee schedule,0.77,111,,,fee schedule,111% of bcbs custom fee schedule,40,50,,32,percent of total billed charges,50% of total billed charges,56,70,,44.8,percent of total billed charges,70% of total billed charges,38.78,48.48,,31.024,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,38.78,48.48,,31.024,percent of total billed charges,48.48% of total billed charges,56,70,,44.8,percent of total billed charges,70% of total billed charges,56,70,,44.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,38.78,48.48,,31.024,percent of total billed charges,48.48% of total billed charges,72,90,,57.6,percent of total billed charges,90% of total billed charges,38.78,90,
CEFTRIAXONE INJ 2 GM,43601503,CDM,636,RC,J0696,HCPCS,outpatient,8,UN,160,96.00,,96,60,,76.8,percent of total billed charges,60% of total billed charges,76.8,48,,61.44,percent of total billed charges,48% of total billed charges,0.69,100,,,fee schedule,100% of bcbs custom fee schedule,0.69,100,,,fee schedule,100% of bcbs custom fee schedule,0.77,111,,,fee schedule,111% of bcbs custom fee schedule,80,50,,64,percent of total billed charges,50% of total billed charges,112,70,,89.6,percent of total billed charges,70% of total billed charges,77.57,48.48,,62.056,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,77.57,48.48,,62.056,percent of total billed charges,48.48% of total billed charges,112,70,,89.6,percent of total billed charges,70% of total billed charges,112,70,,89.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,77.57,48.48,,62.056,percent of total billed charges,48.48% of total billed charges,144,90,,115.2,percent of total billed charges,90% of total billed charges,48.48,144,
NOC^ RAMELTEON TAB [8 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,56,33.60,,33.6,60,,26.88,percent of total billed charges,60% of total billed charges,26.88,48,,21.504,percent of total billed charges,48% of total billed charges,28,50,,22.4,percent of total billed charges,50% of total billed charges,28,50,,22.4,percent of total billed charges,50% of total billed charges,28,50,,22.4,percent of total billed charges,50% of total billed charges,28,50,,22.4,percent of total billed charges,50% of total billed charges,39.2,70,,31.36,percent of total billed charges,70% of total billed charges,27.15,48.48,,21.72,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,27.15,48.48,,21.72,percent of total billed charges,48.48% of total billed charges,39.2,70,,31.36,percent of total billed charges,70% of total billed charges,39.2,70,,31.36,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,27.15,48.48,,21.72,percent of total billed charges,48.48% of total billed charges,50.4,90,,40.32,percent of total billed charges,90% of total billed charges,27.15,90,
NOC^ GALANTAMINE TAB  [4 MG],,,251,RC,J8499,HCPCS,outpatient,1,UN,11,6.60,,6.6,60,,5.28,percent of total billed charges,60% of total billed charges,5.28,48,,4.224,percent of total billed charges,48% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,9.9,90,,7.92,percent of total billed charges,90% of total billed charges,5.33,90,
NOC^ GALANTAMINE ER CAP 24 MG,,,250,RC,J8499,HCPCS,outpatient,1,UN,26,15.60,,15.6,60,,12.48,percent of total billed charges,60% of total billed charges,12.48,48,,9.984,percent of total billed charges,48% of total billed charges,13,50,,10.4,percent of total billed charges,50% of total billed charges,13,50,,10.4,percent of total billed charges,50% of total billed charges,13,50,,10.4,percent of total billed charges,50% of total billed charges,13,50,,10.4,percent of total billed charges,50% of total billed charges,18.2,70,,14.56,percent of total billed charges,70% of total billed charges,12.6,48.48,,10.08,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,12.6,48.48,,10.08,percent of total billed charges,48.48% of total billed charges,18.2,70,,14.56,percent of total billed charges,70% of total billed charges,18.2,70,,14.56,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,12.6,48.48,,10.08,percent of total billed charges,48.48% of total billed charges,23.4,90,,18.72,percent of total billed charges,90% of total billed charges,12.6,90,
NOC^ COLLAGENASE OIN [30GM),,,259,RC,J3490,HCPCS,outpatient,1,UN,892,535.20,,535.2,60,,428.16,percent of total billed charges,60% of total billed charges,428.16,48,,342.528,percent of total billed charges,48% of total billed charges,446,50,,356.8,percent of total billed charges,50% of total billed charges,446,50,,356.8,percent of total billed charges,50% of total billed charges,446,50,,356.8,percent of total billed charges,50% of total billed charges,446,50,,356.8,percent of total billed charges,50% of total billed charges,624.4,70,,499.52,percent of total billed charges,70% of total billed charges,432.44,48.48,,345.952,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,432.44,48.48,,345.952,percent of total billed charges,48.48% of total billed charges,624.4,70,,499.52,percent of total billed charges,70% of total billed charges,624.4,70,,499.52,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,432.44,48.48,,345.952,percent of total billed charges,48.48% of total billed charges,802.8,90,,642.24,percent of total billed charges,90% of total billed charges,48.48,802.8,
NOC^ RISPERIDONE TAB [0.5MG),,,259,RC,J8499,HCPCS,outpatient,1,UN,16,9.60,,9.6,60,,7.68,percent of total billed charges,60% of total billed charges,7.68,48,,6.144,percent of total billed charges,48% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,11.2,70,,8.96,percent of total billed charges,70% of total billed charges,7.76,48.48,,6.208,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,7.76,48.48,,6.208,percent of total billed charges,48.48% of total billed charges,11.2,70,,8.96,percent of total billed charges,70% of total billed charges,11.2,70,,8.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,7.76,48.48,,6.208,percent of total billed charges,48.48% of total billed charges,14.4,90,,11.52,percent of total billed charges,90% of total billed charges,7.76,90,
NOC^ FLUMAZENIL INJ [0.1 MG/ML,,,250,RC,J3490,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
NOC^ VERAPAMIL ER CAP [120 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,22,13.20,,13.2,60,,10.56,percent of total billed charges,60% of total billed charges,10.56,48,,8.448,percent of total billed charges,48% of total billed charges,11,50,,8.8,percent of total billed charges,50% of total billed charges,11,50,,8.8,percent of total billed charges,50% of total billed charges,11,50,,8.8,percent of total billed charges,50% of total billed charges,11,50,,8.8,percent of total billed charges,50% of total billed charges,15.4,70,,12.32,percent of total billed charges,70% of total billed charges,10.67,48.48,,8.536,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,10.67,48.48,,8.536,percent of total billed charges,48.48% of total billed charges,15.4,70,,12.32,percent of total billed charges,70% of total billed charges,15.4,70,,12.32,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,10.67,48.48,,8.536,percent of total billed charges,48.48% of total billed charges,19.8,90,,15.84,percent of total billed charges,90% of total billed charges,10.67,90,
DORZOLAMIDE 2% OPTH,,,259,RC,J8499,HCPCS,outpatient,1,UN,123,73.80,,73.8,60,,59.04,percent of total billed charges,60% of total billed charges,59.04,48,,47.232,percent of total billed charges,48% of total billed charges,61.5,50,,49.2,percent of total billed charges,50% of total billed charges,61.5,50,,49.2,percent of total billed charges,50% of total billed charges,61.5,50,,49.2,percent of total billed charges,50% of total billed charges,61.5,50,,49.2,percent of total billed charges,50% of total billed charges,86.1,70,,68.88,percent of total billed charges,70% of total billed charges,59.63,48.48,,47.704,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,59.63,48.48,,47.704,percent of total billed charges,48.48% of total billed charges,86.1,70,,68.88,percent of total billed charges,70% of total billed charges,86.1,70,,68.88,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,59.63,48.48,,47.704,percent of total billed charges,48.48% of total billed charges,110.7,90,,88.56,percent of total billed charges,90% of total billed charges,48.48,110.7,
NOC^ TIMOLOL OPTH SOL 0.5% 5ML,,,259,RC,J3490,HCPCS,outpatient,1,UN,68,40.80,,40.8,60,,32.64,percent of total billed charges,60% of total billed charges,32.64,48,,26.112,percent of total billed charges,48% of total billed charges,34,50,,27.2,percent of total billed charges,50% of total billed charges,34,50,,27.2,percent of total billed charges,50% of total billed charges,34,50,,27.2,percent of total billed charges,50% of total billed charges,34,50,,27.2,percent of total billed charges,50% of total billed charges,47.6,70,,38.08,percent of total billed charges,70% of total billed charges,32.97,48.48,,26.376,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,32.97,48.48,,26.376,percent of total billed charges,48.48% of total billed charges,47.6,70,,38.08,percent of total billed charges,70% of total billed charges,47.6,70,,38.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,32.97,48.48,,26.376,percent of total billed charges,48.48% of total billed charges,61.2,90,,48.96,percent of total billed charges,90% of total billed charges,32.97,90,
TERAZOL 3 VAGINAL SUPP,,,259,RC,,,outpatient,,,122,73.20,,73.2,60,,58.56,percent of total billed charges,60% of total billed charges,58.56,48,,46.848,percent of total billed charges,48% of total billed charges,61,50,,48.8,percent of total billed charges,50% of total billed charges,61,50,,48.8,percent of total billed charges,50% of total billed charges,61,50,,48.8,percent of total billed charges,50% of total billed charges,61,50,,48.8,percent of total billed charges,50% of total billed charges,85.4,70,,68.32,percent of total billed charges,70% of total billed charges,59.15,48.48,,47.32,percent of total billed charges,48.48% of total billed charges,59.15,48.48,,47.32,percent of total billed charges,48.48% of total billed charges,59.15,48.48,,47.32,percent of total billed charges,48.48% of total billed charges,85.4,70,,68.32,percent of total billed charges,70% of total billed charges,85.4,70,,68.32,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,59.15,48.48,,47.32,percent of total billed charges,48.48% of total billed charges,109.8,90,,87.84,percent of total billed charges,90% of total billed charges,48.48,109.8,
NOC^ TOPIRAMATE TAB  [25 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,17,10.20,,10.2,60,,8.16,percent of total billed charges,60% of total billed charges,8.16,48,,6.528,percent of total billed charges,48% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,11.9,70,,9.52,percent of total billed charges,70% of total billed charges,8.24,48.48,,6.592,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,8.24,48.48,,6.592,percent of total billed charges,48.48% of total billed charges,11.9,70,,9.52,percent of total billed charges,70% of total billed charges,11.9,70,,9.52,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,8.24,48.48,,6.592,percent of total billed charges,48.48% of total billed charges,15.3,90,,12.24,percent of total billed charges,90% of total billed charges,8.24,90,
NOC^ SALMETEROL MDI,,,259,RC,J3490,HCPCS,outpatient,1,UN,1165,699.00,,699,60,,559.2,percent of total billed charges,60% of total billed charges,559.2,48,,447.36,percent of total billed charges,48% of total billed charges,582.5,50,,466,percent of total billed charges,50% of total billed charges,582.5,50,,466,percent of total billed charges,50% of total billed charges,582.5,50,,466,percent of total billed charges,50% of total billed charges,582.5,50,,466,percent of total billed charges,50% of total billed charges,815.5,70,,652.4,percent of total billed charges,70% of total billed charges,564.79,48.48,,451.832,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,564.79,48.48,,451.832,percent of total billed charges,48.48% of total billed charges,815.5,70,,652.4,percent of total billed charges,70% of total billed charges,815.5,70,,652.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,564.79,48.48,,451.832,percent of total billed charges,48.48% of total billed charges,1048.5,90,,838.8,percent of total billed charges,90% of total billed charges,48.48,1048.5,
NOC^ OXCARBAZEPINE TAB 300 MG,,,259,RC,J8499,HCPCS,outpatient,1,UN,12,7.20,,7.2,60,,5.76,percent of total billed charges,60% of total billed charges,5.76,48,,4.608,percent of total billed charges,48% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,8.4,70,,6.72,percent of total billed charges,70% of total billed charges,5.82,48.48,,4.656,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,5.82,48.48,,4.656,percent of total billed charges,48.48% of total billed charges,8.4,70,,6.72,percent of total billed charges,70% of total billed charges,8.4,70,,6.72,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,5.82,48.48,,4.656,percent of total billed charges,48.48% of total billed charges,10.8,90,,8.64,percent of total billed charges,90% of total billed charges,5.82,90,
NOC^ SCOPOLAMINE PAT [1.5 MG],,,259,RC,J3490,HCPCS,outpatient,1,UN,103,61.80,,61.8,60,,49.44,percent of total billed charges,60% of total billed charges,49.44,48,,39.552,percent of total billed charges,48% of total billed charges,51.5,50,,41.2,percent of total billed charges,50% of total billed charges,51.5,50,,41.2,percent of total billed charges,50% of total billed charges,51.5,50,,41.2,percent of total billed charges,50% of total billed charges,51.5,50,,41.2,percent of total billed charges,50% of total billed charges,72.1,70,,57.68,percent of total billed charges,70% of total billed charges,49.93,48.48,,39.944,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,49.93,48.48,,39.944,percent of total billed charges,48.48% of total billed charges,72.1,70,,57.68,percent of total billed charges,70% of total billed charges,72.1,70,,57.68,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,49.93,48.48,,39.944,percent of total billed charges,48.48% of total billed charges,92.7,90,,74.16,percent of total billed charges,90% of total billed charges,48.48,92.7,
NOC^ PAROXETINE TAB [20 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,37,22.20,,22.2,60,,17.76,percent of total billed charges,60% of total billed charges,17.76,48,,14.208,percent of total billed charges,48% of total billed charges,18.5,50,,14.8,percent of total billed charges,50% of total billed charges,18.5,50,,14.8,percent of total billed charges,50% of total billed charges,18.5,50,,14.8,percent of total billed charges,50% of total billed charges,18.5,50,,14.8,percent of total billed charges,50% of total billed charges,25.9,70,,20.72,percent of total billed charges,70% of total billed charges,17.94,48.48,,14.352,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,17.94,48.48,,14.352,percent of total billed charges,48.48% of total billed charges,25.9,70,,20.72,percent of total billed charges,70% of total billed charges,25.9,70,,20.72,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,17.94,48.48,,14.352,percent of total billed charges,48.48% of total billed charges,33.3,90,,26.64,percent of total billed charges,90% of total billed charges,17.94,90,
SEROQUEL XR TAB 300MG,,,259,RC,S5001,HCPCS,outpatient,,,23,13.80,,13.8,60,,11.04,percent of total billed charges,60% of total billed charges,11.04,48,,8.832,percent of total billed charges,48% of total billed charges,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,16.1,70,,12.88,percent of total billed charges,70% of total billed charges,11.15,48.48,,8.92,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,11.15,48.48,,8.92,percent of total billed charges,48.48% of total billed charges,16.1,70,,12.88,percent of total billed charges,70% of total billed charges,16.1,70,,12.88,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,11.15,48.48,,8.92,percent of total billed charges,48.48% of total billed charges,20.7,90,,16.56,percent of total billed charges,90% of total billed charges,11.15,90,
NOC^ NATEGLINIDE TAB 60 MG,,,259,RC,J3490,HCPCS,outpatient,1,UN,11,6.60,,6.6,60,,5.28,percent of total billed charges,60% of total billed charges,5.28,48,,4.224,percent of total billed charges,48% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,9.9,90,,7.92,percent of total billed charges,90% of total billed charges,5.33,90,
NOC^ SILVER SULFADIAZINE 400 G,,,259,RC,J3490,HCPCS,outpatient,1,UN,255,153.00,,153,60,,122.4,percent of total billed charges,60% of total billed charges,122.4,48,,97.92,percent of total billed charges,48% of total billed charges,127.5,50,,102,percent of total billed charges,50% of total billed charges,127.5,50,,102,percent of total billed charges,50% of total billed charges,127.5,50,,102,percent of total billed charges,50% of total billed charges,127.5,50,,102,percent of total billed charges,50% of total billed charges,178.5,70,,142.8,percent of total billed charges,70% of total billed charges,123.62,48.48,,98.896,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,123.62,48.48,,98.896,percent of total billed charges,48.48% of total billed charges,178.5,70,,142.8,percent of total billed charges,70% of total billed charges,178.5,70,,142.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,123.62,48.48,,98.896,percent of total billed charges,48.48% of total billed charges,229.5,90,,183.6,percent of total billed charges,90% of total billed charges,48.48,229.5,
NOC^ METAXALONE TAB [800 MG],,,259,RC,J3490,HCPCS,outpatient,1,UN,22,13.20,,13.2,60,,10.56,percent of total billed charges,60% of total billed charges,10.56,48,,8.448,percent of total billed charges,48% of total billed charges,11,50,,8.8,percent of total billed charges,50% of total billed charges,11,50,,8.8,percent of total billed charges,50% of total billed charges,11,50,,8.8,percent of total billed charges,50% of total billed charges,11,50,,8.8,percent of total billed charges,50% of total billed charges,15.4,70,,12.32,percent of total billed charges,70% of total billed charges,10.67,48.48,,8.536,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,10.67,48.48,,8.536,percent of total billed charges,48.48% of total billed charges,15.4,70,,12.32,percent of total billed charges,70% of total billed charges,15.4,70,,12.32,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,10.67,48.48,,8.536,percent of total billed charges,48.48% of total billed charges,19.8,90,,15.84,percent of total billed charges,90% of total billed charges,10.67,90,
NOC^ TOPIRAMATE TAB [100 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,46,27.60,,27.6,60,,22.08,percent of total billed charges,60% of total billed charges,22.08,48,,17.664,percent of total billed charges,48% of total billed charges,23,50,,18.4,percent of total billed charges,50% of total billed charges,23,50,,18.4,percent of total billed charges,50% of total billed charges,23,50,,18.4,percent of total billed charges,50% of total billed charges,23,50,,18.4,percent of total billed charges,50% of total billed charges,32.2,70,,25.76,percent of total billed charges,70% of total billed charges,22.3,48.48,,17.84,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,22.3,48.48,,17.84,percent of total billed charges,48.48% of total billed charges,32.2,70,,25.76,percent of total billed charges,70% of total billed charges,32.2,70,,25.76,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,22.3,48.48,,17.84,percent of total billed charges,48.48% of total billed charges,41.4,90,,33.12,percent of total billed charges,90% of total billed charges,22.3,90,
NOC^ TACROLIMUS 0.1% OIN,,,259,RC,J3490,HCPCS,outpatient,1,UN,492,295.20,,295.2,60,,236.16,percent of total billed charges,60% of total billed charges,236.16,48,,188.928,percent of total billed charges,48% of total billed charges,246,50,,196.8,percent of total billed charges,50% of total billed charges,246,50,,196.8,percent of total billed charges,50% of total billed charges,246,50,,196.8,percent of total billed charges,50% of total billed charges,246,50,,196.8,percent of total billed charges,50% of total billed charges,344.4,70,,275.52,percent of total billed charges,70% of total billed charges,238.52,48.48,,190.816,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,238.52,48.48,,190.816,percent of total billed charges,48.48% of total billed charges,344.4,70,,275.52,percent of total billed charges,70% of total billed charges,344.4,70,,275.52,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,238.52,48.48,,190.816,percent of total billed charges,48.48% of total billed charges,442.8,90,,354.24,percent of total billed charges,90% of total billed charges,48.48,442.8,
NOC^ SOD BICARB INJ SYR [50 ME,,,250,RC,J3490,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
NOC^ SULFACETAMIDE OPTH SOL 15,,,259,RC,J3490,HCPCS,outpatient,1,UN,223,133.80,,133.8,60,,107.04,percent of total billed charges,60% of total billed charges,107.04,48,,85.632,percent of total billed charges,48% of total billed charges,111.5,50,,89.2,percent of total billed charges,50% of total billed charges,111.5,50,,89.2,percent of total billed charges,50% of total billed charges,111.5,50,,89.2,percent of total billed charges,50% of total billed charges,111.5,50,,89.2,percent of total billed charges,50% of total billed charges,156.1,70,,124.88,percent of total billed charges,70% of total billed charges,108.11,48.48,,86.488,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,108.11,48.48,,86.488,percent of total billed charges,48.48% of total billed charges,156.1,70,,124.88,percent of total billed charges,70% of total billed charges,156.1,70,,124.88,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,108.11,48.48,,86.488,percent of total billed charges,48.48% of total billed charges,200.7,90,,160.56,percent of total billed charges,90% of total billed charges,48.48,200.7,
METHYLPREDNISOL INJ 40MG,43601522,CDM,636,RC,J2919,HCPCS,outpatient,1,UN,30,18.00,,18,60,,14.4,percent of total billed charges,60% of total billed charges,14.4,48,,11.52,percent of total billed charges,48% of total billed charges,15,50,,12,percent of total billed charges,50% of total billed charges,15,50,,12,percent of total billed charges,50% of total billed charges,15,50,,12,percent of total billed charges,50% of total billed charges,15,50,,12,percent of total billed charges,50% of total billed charges,21,70,,16.8,percent of total billed charges,70% of total billed charges,14.54,48.48,,11.632,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,14.54,48.48,,11.632,percent of total billed charges,48.48% of total billed charges,21,70,,16.8,percent of total billed charges,70% of total billed charges,21,70,,16.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,14.54,48.48,,11.632,percent of total billed charges,48.48% of total billed charges,27,90,,21.6,percent of total billed charges,90% of total billed charges,14.54,90,
METHYLPREDNISOL INJ 500MG,,,636,RC,J2930,HCPCS,outpatient,1,UN,197,118.20,,118.2,60,,94.56,percent of total billed charges,60% of total billed charges,94.56,48,,75.648,percent of total billed charges,48% of total billed charges,6.2,100,,,fee schedule,100% of bcbs custom fee schedule,6.2,100,,,fee schedule,100% of bcbs custom fee schedule,6.88,111,,,fee schedule,111% of bcbs custom fee schedule,98.5,50,,78.8,percent of total billed charges,50% of total billed charges,137.9,70,,110.32,percent of total billed charges,70% of total billed charges,95.51,48.48,,76.408,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,95.51,48.48,,76.408,percent of total billed charges,48.48% of total billed charges,137.9,70,,110.32,percent of total billed charges,70% of total billed charges,137.9,70,,110.32,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,95.51,48.48,,76.408,percent of total billed charges,48.48% of total billed charges,177.3,90,,141.84,percent of total billed charges,90% of total billed charges,48.48,177.3,
METHYLPREDNISOL INJ 1GM,43601522,CDM,636,RC,J2919,HCPCS,outpatient,200,UN,212,127.20,,127.2,60,,101.76,percent of total billed charges,60% of total billed charges,101.76,48,,81.408,percent of total billed charges,48% of total billed charges,106,50,,84.8,percent of total billed charges,50% of total billed charges,106,50,,84.8,percent of total billed charges,50% of total billed charges,106,50,,84.8,percent of total billed charges,50% of total billed charges,106,50,,84.8,percent of total billed charges,50% of total billed charges,148.4,70,,118.72,percent of total billed charges,70% of total billed charges,102.78,48.48,,82.224,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,102.78,48.48,,82.224,percent of total billed charges,48.48% of total billed charges,148.4,70,,118.72,percent of total billed charges,70% of total billed charges,148.4,70,,118.72,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,102.78,48.48,,82.224,percent of total billed charges,48.48% of total billed charges,190.8,90,,152.64,percent of total billed charges,90% of total billed charges,48.48,190.8,
SPORANOX CAP 100MG,,,259,RC,,,outpatient,,,23,13.80,,13.8,60,,11.04,percent of total billed charges,60% of total billed charges,11.04,48,,8.832,percent of total billed charges,48% of total billed charges,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,16.1,70,,12.88,percent of total billed charges,70% of total billed charges,11.15,48.48,,8.92,percent of total billed charges,48.48% of total billed charges,11.15,48.48,,8.92,percent of total billed charges,48.48% of total billed charges,11.15,48.48,,8.92,percent of total billed charges,48.48% of total billed charges,16.1,70,,12.88,percent of total billed charges,70% of total billed charges,16.1,70,,12.88,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,11.15,48.48,,8.92,percent of total billed charges,48.48% of total billed charges,20.7,90,,16.56,percent of total billed charges,90% of total billed charges,11.15,90,
TIOTROPIUM MDI,,,259,RC,J3490,HCPCS,outpatient,1,UN,455,273.00,,273,60,,218.4,percent of total billed charges,60% of total billed charges,218.4,48,,174.72,percent of total billed charges,48% of total billed charges,227.5,50,,182,percent of total billed charges,50% of total billed charges,227.5,50,,182,percent of total billed charges,50% of total billed charges,227.5,50,,182,percent of total billed charges,50% of total billed charges,227.5,50,,182,percent of total billed charges,50% of total billed charges,318.5,70,,254.8,percent of total billed charges,70% of total billed charges,220.58,48.48,,176.464,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,220.58,48.48,,176.464,percent of total billed charges,48.48% of total billed charges,318.5,70,,254.8,percent of total billed charges,70% of total billed charges,318.5,70,,254.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,220.58,48.48,,176.464,percent of total billed charges,48.48% of total billed charges,409.5,90,,327.6,percent of total billed charges,90% of total billed charges,48.48,409.5,
BUTORPHANOL INJ 2MG/ML,,,636,RC,J0595,HCPCS,outpatient,1,UN,26,15.60,,15.6,60,,12.48,percent of total billed charges,60% of total billed charges,12.48,48,,9.984,percent of total billed charges,48% of total billed charges,3.18,100,,,fee schedule,100% of bcbs custom fee schedule,3.18,100,,,fee schedule,100% of bcbs custom fee schedule,3.53,111,,,fee schedule,111% of bcbs custom fee schedule,13,50,,10.4,percent of total billed charges,50% of total billed charges,18.2,70,,14.56,percent of total billed charges,70% of total billed charges,12.6,48.48,,10.08,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,12.6,48.48,,10.08,percent of total billed charges,48.48% of total billed charges,18.2,70,,14.56,percent of total billed charges,70% of total billed charges,18.2,70,,14.56,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,12.6,48.48,,10.08,percent of total billed charges,48.48% of total billed charges,23.4,90,,18.72,percent of total billed charges,90% of total billed charges,12.6,90,
NOC^ DNS-NATEGLINIDE TAB [120,,,259,RC,J3490,HCPCS,outpatient,1,UN,11,6.60,,6.6,60,,5.28,percent of total billed charges,60% of total billed charges,5.28,48,,4.224,percent of total billed charges,48% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,9.9,90,,7.92,percent of total billed charges,90% of total billed charges,5.33,90,
TETRACYCLINE CAP [250 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,32,19.20,,19.2,60,,15.36,percent of total billed charges,60% of total billed charges,15.36,48,,12.288,percent of total billed charges,48% of total billed charges,16,50,,12.8,percent of total billed charges,50% of total billed charges,16,50,,12.8,percent of total billed charges,50% of total billed charges,16,50,,12.8,percent of total billed charges,50% of total billed charges,16,50,,12.8,percent of total billed charges,50% of total billed charges,22.4,70,,17.92,percent of total billed charges,70% of total billed charges,15.51,48.48,,12.408,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,15.51,48.48,,12.408,percent of total billed charges,48.48% of total billed charges,22.4,70,,17.92,percent of total billed charges,70% of total billed charges,22.4,70,,17.92,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,15.51,48.48,,12.408,percent of total billed charges,48.48% of total billed charges,28.8,90,,23.04,percent of total billed charges,90% of total billed charges,15.51,90,
NOC^ AMANTADINE CAP [100 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,14,8.40,,8.4,60,,6.72,percent of total billed charges,60% of total billed charges,6.72,48,,5.376,percent of total billed charges,48% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,9.8,70,,7.84,percent of total billed charges,70% of total billed charges,6.79,48.48,,5.432,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,6.79,48.48,,5.432,percent of total billed charges,48.48% of total billed charges,9.8,70,,7.84,percent of total billed charges,70% of total billed charges,9.8,70,,7.84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,6.79,48.48,,5.432,percent of total billed charges,48.48% of total billed charges,12.6,90,,10.08,percent of total billed charges,90% of total billed charges,6.79,90,
NOC^ QUETIAPINE TAB [25 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,16,9.60,,9.6,60,,7.68,percent of total billed charges,60% of total billed charges,7.68,48,,6.144,percent of total billed charges,48% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,11.2,70,,8.96,percent of total billed charges,70% of total billed charges,7.76,48.48,,6.208,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,7.76,48.48,,6.208,percent of total billed charges,48.48% of total billed charges,11.2,70,,8.96,percent of total billed charges,70% of total billed charges,11.2,70,,8.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,7.76,48.48,,6.208,percent of total billed charges,48.48% of total billed charges,14.4,90,,11.52,percent of total billed charges,90% of total billed charges,7.76,90,
NOC^ MONTELUKAST TAB [10 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,23,13.80,,13.8,60,,11.04,percent of total billed charges,60% of total billed charges,11.04,48,,8.832,percent of total billed charges,48% of total billed charges,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,16.1,70,,12.88,percent of total billed charges,70% of total billed charges,11.15,48.48,,8.92,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,11.15,48.48,,8.92,percent of total billed charges,48.48% of total billed charges,16.1,70,,12.88,percent of total billed charges,70% of total billed charges,16.1,70,,12.88,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,11.15,48.48,,8.92,percent of total billed charges,48.48% of total billed charges,20.7,90,,16.56,percent of total billed charges,90% of total billed charges,11.15,90,
NOC^ PROPYLENE GLYCOL/PEG EYE,,,259,RC,J3490,HCPCS,outpatient,1,UN,43,25.80,,25.8,60,,20.64,percent of total billed charges,60% of total billed charges,20.64,48,,16.512,percent of total billed charges,48% of total billed charges,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,30.1,70,,24.08,percent of total billed charges,70% of total billed charges,20.85,48.48,,16.68,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,20.85,48.48,,16.68,percent of total billed charges,48.48% of total billed charges,30.1,70,,24.08,percent of total billed charges,70% of total billed charges,30.1,70,,24.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,20.85,48.48,,16.68,percent of total billed charges,48.48% of total billed charges,38.7,90,,30.96,percent of total billed charges,90% of total billed charges,20.85,90,
NOC^ TRIAMCINOLONE 0.025% CRM,,,259,RC,J3490,HCPCS,outpatient,1,UN,10,6.00,,6,60,,4.8,percent of total billed charges,60% of total billed charges,4.8,48,,3.84,percent of total billed charges,48% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,7,70,,5.6,percent of total billed charges,70% of total billed charges,4.85,48.48,,3.88,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,4.85,48.48,,3.88,percent of total billed charges,48.48% of total billed charges,7,70,,5.6,percent of total billed charges,70% of total billed charges,7,70,,5.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,4.85,48.48,,3.88,percent of total billed charges,48.48% of total billed charges,9,90,,7.2,percent of total billed charges,90% of total billed charges,4.85,90,
TAPAZOLE TAB 5MG,,,259,RC,,,outpatient,,,10,6.00,,6,60,,4.8,percent of total billed charges,60% of total billed charges,4.8,48,,3.84,percent of total billed charges,48% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,7,70,,5.6,percent of total billed charges,70% of total billed charges,4.85,48.48,,3.88,percent of total billed charges,48.48% of total billed charges,4.85,48.48,,3.88,percent of total billed charges,48.48% of total billed charges,4.85,48.48,,3.88,percent of total billed charges,48.48% of total billed charges,7,70,,5.6,percent of total billed charges,70% of total billed charges,7,70,,5.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,4.85,48.48,,3.88,percent of total billed charges,48.48% of total billed charges,9,90,,7.2,percent of total billed charges,90% of total billed charges,4.85,90,
NOC^ FENOFIBRATE TAB [145 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,21,12.60,,12.6,60,,10.08,percent of total billed charges,60% of total billed charges,10.08,48,,8.064,percent of total billed charges,48% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,14.7,70,,11.76,percent of total billed charges,70% of total billed charges,10.18,48.48,,8.144,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,10.18,48.48,,8.144,percent of total billed charges,48.48% of total billed charges,14.7,70,,11.76,percent of total billed charges,70% of total billed charges,14.7,70,,11.76,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,10.18,48.48,,8.144,percent of total billed charges,48.48% of total billed charges,18.9,90,,15.12,percent of total billed charges,90% of total billed charges,10.18,90,
NOC^ QUETIAPINE TAB [100 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,32,19.20,,19.2,60,,15.36,percent of total billed charges,60% of total billed charges,15.36,48,,12.288,percent of total billed charges,48% of total billed charges,16,50,,12.8,percent of total billed charges,50% of total billed charges,16,50,,12.8,percent of total billed charges,50% of total billed charges,16,50,,12.8,percent of total billed charges,50% of total billed charges,16,50,,12.8,percent of total billed charges,50% of total billed charges,22.4,70,,17.92,percent of total billed charges,70% of total billed charges,15.51,48.48,,12.408,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,15.51,48.48,,12.408,percent of total billed charges,48.48% of total billed charges,22.4,70,,17.92,percent of total billed charges,70% of total billed charges,22.4,70,,17.92,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,15.51,48.48,,12.408,percent of total billed charges,48.48% of total billed charges,28.8,90,,23.04,percent of total billed charges,90% of total billed charges,15.51,90,
VIT- B-1 INJ [100 MG/ML],,,250,RC,J3411,HCPCS,outpatient,1,UN,43,25.80,,25.8,60,,20.64,percent of total billed charges,60% of total billed charges,20.64,48,,16.512,percent of total billed charges,48% of total billed charges,2.78,100,,,fee schedule,100% of bcbs custom fee schedule,2.78,100,,,fee schedule,100% of bcbs custom fee schedule,3.09,111,,,fee schedule,111% of bcbs custom fee schedule,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,30.1,70,,24.08,percent of total billed charges,70% of total billed charges,20.85,48.48,,16.68,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,20.85,48.48,,16.68,percent of total billed charges,48.48% of total billed charges,30.1,70,,24.08,percent of total billed charges,70% of total billed charges,30.1,70,,24.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,20.85,48.48,,16.68,percent of total billed charges,48.48% of total billed charges,38.7,90,,30.96,percent of total billed charges,90% of total billed charges,20.85,90,
CHLORPROMAZINE INJ [25 MG,,,636,RC,J3230,HCPCS,outpatient,1,UN,139,83.40,,83.4,60,,66.72,percent of total billed charges,60% of total billed charges,66.72,48,,53.376,percent of total billed charges,48% of total billed charges,38.08,100,,,fee schedule,100% of bcbs custom fee schedule,38.08,100,,,fee schedule,100% of bcbs custom fee schedule,42.27,111,,,fee schedule,111% of bcbs custom fee schedule,69.5,50,,55.6,percent of total billed charges,50% of total billed charges,97.3,70,,77.84,percent of total billed charges,70% of total billed charges,67.39,48.48,,53.912,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,67.39,48.48,,53.912,percent of total billed charges,48.48% of total billed charges,97.3,70,,77.84,percent of total billed charges,70% of total billed charges,97.3,70,,77.84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,67.39,48.48,,53.912,percent of total billed charges,48.48% of total billed charges,125.1,90,,100.08,percent of total billed charges,90% of total billed charges,48.48,125.1,
CHLORPROMAZINE TAB  [25 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,30,18.00,,18,60,,14.4,percent of total billed charges,60% of total billed charges,14.4,48,,11.52,percent of total billed charges,48% of total billed charges,15,50,,12,percent of total billed charges,50% of total billed charges,15,50,,12,percent of total billed charges,50% of total billed charges,15,50,,12,percent of total billed charges,50% of total billed charges,15,50,,12,percent of total billed charges,50% of total billed charges,21,70,,16.8,percent of total billed charges,70% of total billed charges,14.54,48.48,,11.632,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,14.54,48.48,,11.632,percent of total billed charges,48.48% of total billed charges,21,70,,16.8,percent of total billed charges,70% of total billed charges,21,70,,16.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,14.54,48.48,,11.632,percent of total billed charges,48.48% of total billed charges,27,90,,21.6,percent of total billed charges,90% of total billed charges,14.54,90,
TENECTEPLASE INJ [50 MG],,,636,RC,J3101,HCPCS,outpatient,1,UN,17708,10624.80,,10624.8,60,,8499.84,percent of total billed charges,60% of total billed charges,8499.84,48,,6799.872,percent of total billed charges,48% of total billed charges,142.19,100,,,fee schedule,100% of bcbs custom fee schedule,142.19,100,,,fee schedule,100% of bcbs custom fee schedule,157.83,111,,,fee schedule,111% of bcbs custom fee schedule,8854,50,,7083.2,percent of total billed charges,50% of total billed charges,12395.6,70,,9916.48,percent of total billed charges,70% of total billed charges,8584.84,48.48,,6867.872,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,8584.84,48.48,,6867.872,percent of total billed charges,48.48% of total billed charges,12395.6,70,,9916.48,percent of total billed charges,70% of total billed charges,12395.6,70,,9916.48,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,8584.84,48.48,,6867.872,percent of total billed charges,48.48% of total billed charges,15937.2,90,,12749.76,percent of total billed charges,90% of total billed charges,48.48,15937.2,
TRIMETHOBENZAMIDE INJ 200,,,250,RC,J3250,HCPCS,outpatient,1,UN,214,128.40,,128.4,60,,102.72,percent of total billed charges,60% of total billed charges,102.72,48,,82.176,percent of total billed charges,48% of total billed charges,40.49,100,,,fee schedule,100% of bcbs custom fee schedule,40.49,100,,,fee schedule,100% of bcbs custom fee schedule,44.94,111,,,fee schedule,111% of bcbs custom fee schedule,107,50,,85.6,percent of total billed charges,50% of total billed charges,149.8,70,,119.84,percent of total billed charges,70% of total billed charges,103.75,48.48,,83,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,103.75,48.48,,83,percent of total billed charges,48.48% of total billed charges,149.8,70,,119.84,percent of total billed charges,70% of total billed charges,149.8,70,,119.84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,103.75,48.48,,83,percent of total billed charges,48.48% of total billed charges,192.6,90,,154.08,percent of total billed charges,90% of total billed charges,48.48,192.6,
TICARCILLIN/ CLAV INJ [3.,,,250,RC,S0040,HCPCS,outpatient,1,UN,64,38.40,,38.4,60,,30.72,percent of total billed charges,60% of total billed charges,30.72,48,,24.576,percent of total billed charges,48% of total billed charges,14.4,100,,,fee schedule,100% of bcbs custom fee schedule,14.4,100,,,fee schedule,100% of bcbs custom fee schedule,15.98,111,,,fee schedule,111% of bcbs custom fee schedule,32,50,,25.6,percent of total billed charges,50% of total billed charges,44.8,70,,35.84,percent of total billed charges,70% of total billed charges,31.03,48.48,,24.824,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,31.03,48.48,,24.824,percent of total billed charges,48.48% of total billed charges,44.8,70,,35.84,percent of total billed charges,70% of total billed charges,44.8,70,,35.84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,31.03,48.48,,24.824,percent of total billed charges,48.48% of total billed charges,57.6,90,,46.08,percent of total billed charges,90% of total billed charges,31.03,90,
NOC^ TRAVOPROST DRP [EYE],,,259,RC,J3490,HCPCS,outpatient,1,UN,828,496.80,,496.8,60,,397.44,percent of total billed charges,60% of total billed charges,397.44,48,,317.952,percent of total billed charges,48% of total billed charges,414,50,,331.2,percent of total billed charges,50% of total billed charges,414,50,,331.2,percent of total billed charges,50% of total billed charges,414,50,,331.2,percent of total billed charges,50% of total billed charges,414,50,,331.2,percent of total billed charges,50% of total billed charges,579.6,70,,463.68,percent of total billed charges,70% of total billed charges,401.41,48.48,,321.128,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,401.41,48.48,,321.128,percent of total billed charges,48.48% of total billed charges,579.6,70,,463.68,percent of total billed charges,70% of total billed charges,579.6,70,,463.68,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,401.41,48.48,,321.128,percent of total billed charges,48.48% of total billed charges,745.2,90,,596.16,percent of total billed charges,90% of total billed charges,48.48,745.2,
TUBERCULIN PPD INJ [5 TU/,43601401,CDM,250,RC,86580,HCPCS,outpatient,1,UN,44,26.40,,26.4,60,,21.12,percent of total billed charges,60% of total billed charges,21.12,48,,16.896,percent of total billed charges,48% of total billed charges,19.36,100,,,fee schedule,100% of bcbs custom fee schedule,19.36,100,,,fee schedule,100% of bcbs custom fee schedule,21.49,111,,,fee schedule,111% of bcbs custom fee schedule,22,50,,17.6,percent of total billed charges,50% of total billed charges,30.8,70,,24.64,percent of total billed charges,70% of total billed charges,21.33,48.48,,17.064,percent of total billed charges,48.48% of total billed charges,10.59,116.15,,,fee schedule,116.51% of cms physician fee schedule,21.33,48.48,,17.064,percent of total billed charges,48.48% of total billed charges,30.8,70,,24.64,percent of total billed charges,70% of total billed charges,30.8,70,,24.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,21.33,48.48,,17.064,percent of total billed charges,48.48% of total billed charges,39.6,90,,31.68,percent of total billed charges,90% of total billed charges,21.33,90,
TYPHOID VACC 0.5 ML,,,636,RC,J8499,HCPCS,outpatient,1,UN,130,78.00,,78,60,,62.4,percent of total billed charges,60% of total billed charges,62.4,48,,49.92,percent of total billed charges,48% of total billed charges,65,50,,52,percent of total billed charges,50% of total billed charges,65,50,,52,percent of total billed charges,50% of total billed charges,65,50,,52,percent of total billed charges,50% of total billed charges,65,50,,52,percent of total billed charges,50% of total billed charges,91,70,,72.8,percent of total billed charges,70% of total billed charges,63.02,48.48,,50.416,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,63.02,48.48,,50.416,percent of total billed charges,48.48% of total billed charges,91,70,,72.8,percent of total billed charges,70% of total billed charges,91,70,,72.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,63.02,48.48,,50.416,percent of total billed charges,48.48% of total billed charges,117,90,,93.6,percent of total billed charges,90% of total billed charges,48.48,117,
AMPICILLIN/ SULB INJ [1.5,,,636,RC,J0295,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,2.9,100,,,fee schedule,100% of bcbs custom fee schedule,2.9,100,,,fee schedule,100% of bcbs custom fee schedule,3.22,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
AMPICILLIN/ SULB INJ [3 G,,,636,RC,J0295,HCPCS,outpatient,2,UN,70,42.00,,42,60,,33.6,percent of total billed charges,60% of total billed charges,33.6,48,,26.88,percent of total billed charges,48% of total billed charges,2.9,100,,,fee schedule,100% of bcbs custom fee schedule,2.9,100,,,fee schedule,100% of bcbs custom fee schedule,3.22,111,,,fee schedule,111% of bcbs custom fee schedule,35,50,,28,percent of total billed charges,50% of total billed charges,49,70,,39.2,percent of total billed charges,70% of total billed charges,33.94,48.48,,27.152,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,33.94,48.48,,27.152,percent of total billed charges,48.48% of total billed charges,49,70,,39.2,percent of total billed charges,70% of total billed charges,49,70,,39.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,33.94,48.48,,27.152,percent of total billed charges,48.48% of total billed charges,63,90,,50.4,percent of total billed charges,90% of total billed charges,33.94,90,
NOC^ BETHANECHOL TAB [25 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,11,6.60,,6.6,60,,5.28,percent of total billed charges,60% of total billed charges,5.28,48,,4.224,percent of total billed charges,48% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,9.9,90,,7.92,percent of total billed charges,90% of total billed charges,5.33,90,
NOC^ ALFUZOSIN ER TAB [10 MG],,,259,RC,J3490,HCPCS,outpatient,1,UN,17,10.20,,10.2,60,,8.16,percent of total billed charges,60% of total billed charges,8.16,48,,6.528,percent of total billed charges,48% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,11.9,70,,9.52,percent of total billed charges,70% of total billed charges,8.24,48.48,,6.592,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,8.24,48.48,,6.592,percent of total billed charges,48.48% of total billed charges,11.9,70,,9.52,percent of total billed charges,70% of total billed charges,11.9,70,,9.52,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,8.24,48.48,,6.592,percent of total billed charges,48.48% of total billed charges,15.3,90,,12.24,percent of total billed charges,90% of total billed charges,8.24,90,
NOC^ LABETALOL INJ 100MG/20 ML,,,636,RC,J1920,HCPCS,outpatient,1,UN,125,75.00,,75,60,,60,percent of total billed charges,60% of total billed charges,60,48,,48,percent of total billed charges,48% of total billed charges,62.5,50,,50,percent of total billed charges,50% of total billed charges,62.5,50,,50,percent of total billed charges,50% of total billed charges,62.5,50,,50,percent of total billed charges,50% of total billed charges,62.5,50,,50,percent of total billed charges,50% of total billed charges,87.5,70,,70,percent of total billed charges,70% of total billed charges,60.6,48.48,,48.48,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,60.6,48.48,,48.48,percent of total billed charges,48.48% of total billed charges,87.5,70,,70,percent of total billed charges,70% of total billed charges,87.5,70,,70,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,60.6,48.48,,48.48,percent of total billed charges,48.48% of total billed charges,112.5,90,,90,percent of total billed charges,90% of total billed charges,48.48,112.5,
NOC^ BUPROPION XL TAB 150 MG,,,259,RC,J8499,HCPCS,outpatient,1,UN,19,11.40,,11.4,60,,9.12,percent of total billed charges,60% of total billed charges,9.12,48,,7.296,percent of total billed charges,48% of total billed charges,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,13.3,70,,10.64,percent of total billed charges,70% of total billed charges,9.21,48.48,,7.368,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.21,48.48,,7.368,percent of total billed charges,48.48% of total billed charges,13.3,70,,10.64,percent of total billed charges,70% of total billed charges,13.3,70,,10.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.21,48.48,,7.368,percent of total billed charges,48.48% of total billed charges,17.1,90,,13.68,percent of total billed charges,90% of total billed charges,9.21,90,
BUPROPION XL TAB [300 MG],,,259,RC,S5000,HCPCS,outpatient,1,UN,36,21.60,,21.6,60,,17.28,percent of total billed charges,60% of total billed charges,17.28,48,,13.824,percent of total billed charges,48% of total billed charges,18,50,,14.4,percent of total billed charges,50% of total billed charges,18,50,,14.4,percent of total billed charges,50% of total billed charges,18,50,,14.4,percent of total billed charges,50% of total billed charges,18,50,,14.4,percent of total billed charges,50% of total billed charges,25.2,70,,20.16,percent of total billed charges,70% of total billed charges,17.45,48.48,,13.96,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,17.45,48.48,,13.96,percent of total billed charges,48.48% of total billed charges,25.2,70,,20.16,percent of total billed charges,70% of total billed charges,25.2,70,,20.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,17.45,48.48,,13.96,percent of total billed charges,48.48% of total billed charges,32.4,90,,25.92,percent of total billed charges,90% of total billed charges,17.45,90,
LIDOCAINE 2G/D5 500ML,,,636,RC,J2001,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,0.02,100,,,fee schedule,100% of bcbs custom fee schedule,0.02,100,,,fee schedule,100% of bcbs custom fee schedule,0.02,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
NOC^ DICLOFENAC OPT SOL 0.1%,,,259,RC,J3490,HCPCS,outpatient,1,UN,70,42.00,,42,60,,33.6,percent of total billed charges,60% of total billed charges,33.6,48,,26.88,percent of total billed charges,48% of total billed charges,35,50,,28,percent of total billed charges,50% of total billed charges,35,50,,28,percent of total billed charges,50% of total billed charges,35,50,,28,percent of total billed charges,50% of total billed charges,35,50,,28,percent of total billed charges,50% of total billed charges,49,70,,39.2,percent of total billed charges,70% of total billed charges,33.94,48.48,,27.152,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,33.94,48.48,,27.152,percent of total billed charges,48.48% of total billed charges,49,70,,39.2,percent of total billed charges,70% of total billed charges,49,70,,39.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,33.94,48.48,,27.152,percent of total billed charges,48.48% of total billed charges,63,90,,50.4,percent of total billed charges,90% of total billed charges,33.94,90,
NOC^ ENALAPRILAT INJ [2.5 mg/2ml),,,250,RC,J3490,HCPCS,outpatient,1,UN,42,25.20,,25.2,60,,20.16,percent of total billed charges,60% of total billed charges,20.16,48,,16.128,percent of total billed charges,48% of total billed charges,21,50,,16.8,percent of total billed charges,50% of total billed charges,21,50,,16.8,percent of total billed charges,50% of total billed charges,21,50,,16.8,percent of total billed charges,50% of total billed charges,21,50,,16.8,percent of total billed charges,50% of total billed charges,29.4,70,,23.52,percent of total billed charges,70% of total billed charges,20.36,48.48,,16.288,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,20.36,48.48,,16.288,percent of total billed charges,48.48% of total billed charges,29.4,70,,23.52,percent of total billed charges,70% of total billed charges,29.4,70,,23.52,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,20.36,48.48,,16.288,percent of total billed charges,48.48% of total billed charges,37.8,90,,30.24,percent of total billed charges,90% of total billed charges,20.36,90,
DIAZEPAM INJ SYR [10 MG/2,,,636,RC,J3360,HCPCS,outpatient,1,UN,193,115.80,,115.8,60,,92.64,percent of total billed charges,60% of total billed charges,92.64,48,,74.112,percent of total billed charges,48% of total billed charges,6.66,100,,,fee schedule,100% of bcbs custom fee schedule,6.66,100,,,fee schedule,100% of bcbs custom fee schedule,7.39,111,,,fee schedule,111% of bcbs custom fee schedule,96.5,50,,77.2,percent of total billed charges,50% of total billed charges,135.1,70,,108.08,percent of total billed charges,70% of total billed charges,93.57,48.48,,74.856,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,93.57,48.48,,74.856,percent of total billed charges,48.48% of total billed charges,135.1,70,,108.08,percent of total billed charges,70% of total billed charges,135.1,70,,108.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,93.57,48.48,,74.856,percent of total billed charges,48.48% of total billed charges,173.7,90,,138.96,percent of total billed charges,90% of total billed charges,48.48,173.7,
VANCOMYCIN SUSP 250MG/5ML 4 OZ,,,259,RC,,,outpatient,,,413,247.80,,247.8,60,,198.24,percent of total billed charges,60% of total billed charges,198.24,48,,158.592,percent of total billed charges,48% of total billed charges,206.5,50,,165.2,percent of total billed charges,50% of total billed charges,206.5,50,,165.2,percent of total billed charges,50% of total billed charges,206.5,50,,165.2,percent of total billed charges,50% of total billed charges,206.5,50,,165.2,percent of total billed charges,50% of total billed charges,289.1,70,,231.28,percent of total billed charges,70% of total billed charges,200.22,48.48,,160.176,percent of total billed charges,48.48% of total billed charges,200.22,48.48,,160.176,percent of total billed charges,48.48% of total billed charges,200.22,48.48,,160.176,percent of total billed charges,48.48% of total billed charges,289.1,70,,231.28,percent of total billed charges,70% of total billed charges,289.1,70,,231.28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,200.22,48.48,,160.176,percent of total billed charges,48.48% of total billed charges,371.7,90,,297.36,percent of total billed charges,90% of total billed charges,48.48,371.7,
VANCOMYCIN 500 MG VIAL,,,636,RC,J3370,HCPCS,outpatient,1,UN,52,31.20,,31.2,60,,24.96,percent of total billed charges,60% of total billed charges,24.96,48,,19.968,percent of total billed charges,48% of total billed charges,3.05,100,,,fee schedule,100% of bcbs custom fee schedule,3.05,100,,,fee schedule,100% of bcbs custom fee schedule,3.39,111,,,fee schedule,111% of bcbs custom fee schedule,26,50,,20.8,percent of total billed charges,50% of total billed charges,36.4,70,,29.12,percent of total billed charges,70% of total billed charges,25.21,48.48,,20.168,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,25.21,48.48,,20.168,percent of total billed charges,48.48% of total billed charges,36.4,70,,29.12,percent of total billed charges,70% of total billed charges,36.4,70,,29.12,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,25.21,48.48,,20.168,percent of total billed charges,48.48% of total billed charges,46.8,90,,37.44,percent of total billed charges,90% of total billed charges,25.21,90,
VANCOMYCIN INJ 750 MG,,,636,RC,J3370,HCPCS,outpatient,2,UN,46,27.60,,27.6,60,,22.08,percent of total billed charges,60% of total billed charges,22.08,48,,17.664,percent of total billed charges,48% of total billed charges,3.05,100,,,fee schedule,100% of bcbs custom fee schedule,3.05,100,,,fee schedule,100% of bcbs custom fee schedule,3.39,111,,,fee schedule,111% of bcbs custom fee schedule,23,50,,18.4,percent of total billed charges,50% of total billed charges,32.2,70,,25.76,percent of total billed charges,70% of total billed charges,22.3,48.48,,17.84,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,22.3,48.48,,17.84,percent of total billed charges,48.48% of total billed charges,32.2,70,,25.76,percent of total billed charges,70% of total billed charges,32.2,70,,25.76,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,22.3,48.48,,17.84,percent of total billed charges,48.48% of total billed charges,41.4,90,,33.12,percent of total billed charges,90% of total billed charges,22.3,90,
VANCOMYCIN INJ 1 GM,,,636,RC,J3370,HCPCS,outpatient,2,UN,155,93.00,,93,60,,74.4,percent of total billed charges,60% of total billed charges,74.4,48,,59.52,percent of total billed charges,48% of total billed charges,3.05,100,,,fee schedule,100% of bcbs custom fee schedule,3.05,100,,,fee schedule,100% of bcbs custom fee schedule,3.39,111,,,fee schedule,111% of bcbs custom fee schedule,77.5,50,,62,percent of total billed charges,50% of total billed charges,108.5,70,,86.8,percent of total billed charges,70% of total billed charges,75.14,48.48,,60.112,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,75.14,48.48,,60.112,percent of total billed charges,48.48% of total billed charges,108.5,70,,86.8,percent of total billed charges,70% of total billed charges,108.5,70,,86.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,75.14,48.48,,60.112,percent of total billed charges,48.48% of total billed charges,139.5,90,,111.6,percent of total billed charges,90% of total billed charges,48.48,139.5,
NOC^ VALACYCLOVIR TAB [500 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,33,19.80,,19.8,60,,15.84,percent of total billed charges,60% of total billed charges,15.84,48,,12.672,percent of total billed charges,48% of total billed charges,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,23.1,70,,18.48,percent of total billed charges,70% of total billed charges,16,48.48,,12.8,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,16,48.48,,12.8,percent of total billed charges,48.48% of total billed charges,23.1,70,,18.48,percent of total billed charges,70% of total billed charges,23.1,70,,18.48,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,16,48.48,,12.8,percent of total billed charges,48.48% of total billed charges,29.7,90,,23.76,percent of total billed charges,90% of total billed charges,16,90,
VANCOMYCIN CAP 125 MG,,,259,RC,J8499,HCPCS,outpatient,1,UN,126,75.60,,75.6,60,,60.48,percent of total billed charges,60% of total billed charges,60.48,48,,48.384,percent of total billed charges,48% of total billed charges,63,50,,50.4,percent of total billed charges,50% of total billed charges,63,50,,50.4,percent of total billed charges,50% of total billed charges,63,50,,50.4,percent of total billed charges,50% of total billed charges,63,50,,50.4,percent of total billed charges,50% of total billed charges,88.2,70,,70.56,percent of total billed charges,70% of total billed charges,61.08,48.48,,48.864,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,61.08,48.48,,48.864,percent of total billed charges,48.48% of total billed charges,88.2,70,,70.56,percent of total billed charges,70% of total billed charges,88.2,70,,70.56,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,61.08,48.48,,48.864,percent of total billed charges,48.48% of total billed charges,113.4,90,,90.72,percent of total billed charges,90% of total billed charges,48.48,113.4,
NOC^ VANCOMYCIN CAP [250 MG],,,250,RC,J3490,HCPCS,outpatient,1,UN,231,138.60,,138.6,60,,110.88,percent of total billed charges,60% of total billed charges,110.88,48,,88.704,percent of total billed charges,48% of total billed charges,115.5,50,,92.4,percent of total billed charges,50% of total billed charges,115.5,50,,92.4,percent of total billed charges,50% of total billed charges,115.5,50,,92.4,percent of total billed charges,50% of total billed charges,115.5,50,,92.4,percent of total billed charges,50% of total billed charges,161.7,70,,129.36,percent of total billed charges,70% of total billed charges,111.99,48.48,,89.592,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,111.99,48.48,,89.592,percent of total billed charges,48.48% of total billed charges,161.7,70,,129.36,percent of total billed charges,70% of total billed charges,161.7,70,,129.36,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,111.99,48.48,,89.592,percent of total billed charges,48.48% of total billed charges,207.9,90,,166.32,percent of total billed charges,90% of total billed charges,48.48,207.9,
HEP A VACC 1 ML,43601403,CDM,636,RC,90632,HCPCS,outpatient,1,UN,166,99.60,,99.6,60,,79.68,percent of total billed charges,60% of total billed charges,79.68,48,,63.744,percent of total billed charges,48% of total billed charges,64.28,100,,,fee schedule,100% of bcbs custom fee schedule,64.28,100,,,fee schedule,100% of bcbs custom fee schedule,71.35,111,,,fee schedule,111% of bcbs custom fee schedule,83,50,,66.4,percent of total billed charges,50% of total billed charges,116.2,70,,92.96,percent of total billed charges,70% of total billed charges,80.48,48.48,,64.384,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,80.48,48.48,,64.384,percent of total billed charges,48.48% of total billed charges,116.2,70,,92.96,percent of total billed charges,70% of total billed charges,116.2,70,,92.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,80.48,48.48,,64.384,percent of total billed charges,48.48% of total billed charges,149.4,90,,119.52,percent of total billed charges,90% of total billed charges,48.48,149.4,
NOC^ DOXYCYCLINE TAB [100 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,23,13.80,,13.8,60,,11.04,percent of total billed charges,60% of total billed charges,11.04,48,,8.832,percent of total billed charges,48% of total billed charges,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,16.1,70,,12.88,percent of total billed charges,70% of total billed charges,11.15,48.48,,8.92,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,11.15,48.48,,8.92,percent of total billed charges,48.48% of total billed charges,16.1,70,,12.88,percent of total billed charges,70% of total billed charges,16.1,70,,12.88,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,11.15,48.48,,8.92,percent of total billed charges,48.48% of total billed charges,20.7,90,,16.56,percent of total billed charges,90% of total billed charges,11.15,90,
HYDROXYZINE INJ [50 MG/ML,,,636,RC,J3410,HCPCS,outpatient,1,UN,113,67.80,,67.8,60,,54.24,percent of total billed charges,60% of total billed charges,54.24,48,,43.392,percent of total billed charges,48% of total billed charges,8.61,100,,,fee schedule,100% of bcbs custom fee schedule,8.61,100,,,fee schedule,100% of bcbs custom fee schedule,9.56,111,,,fee schedule,111% of bcbs custom fee schedule,56.5,50,,45.2,percent of total billed charges,50% of total billed charges,79.1,70,,63.28,percent of total billed charges,70% of total billed charges,54.78,48.48,,43.824,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,54.78,48.48,,43.824,percent of total billed charges,48.48% of total billed charges,79.1,70,,63.28,percent of total billed charges,70% of total billed charges,79.1,70,,63.28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,54.78,48.48,,43.824,percent of total billed charges,48.48% of total billed charges,101.7,90,,81.36,percent of total billed charges,90% of total billed charges,48.48,101.7,
VIT K INJ 10MG PER 1MG,,,250,RC,J3430,HCPCS,outpatient,,,16.5,9.90,,9.9,60,,7.92,percent of total billed charges,60% of total billed charges,7.92,48,,6.336,percent of total billed charges,48% of total billed charges,4.19,100,,,fee schedule,100% of bcbs custom fee schedule,4.19,100,,,fee schedule,100% of bcbs custom fee schedule,4.65,111,,,fee schedule,111% of bcbs custom fee schedule,8.25,50,,6.6,percent of total billed charges,50% of total billed charges,11.55,70,,9.24,percent of total billed charges,70% of total billed charges,8,48.48,,6.4,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,8,48.48,,6.4,percent of total billed charges,48.48% of total billed charges,11.55,70,,9.24,percent of total billed charges,70% of total billed charges,11.55,70,,9.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,8,48.48,,6.4,percent of total billed charges,48.48% of total billed charges,14.85,90,,11.88,percent of total billed charges,90% of total billed charges,8,90,
KETOROLAC INJ 30MG/ML,43601515,CDM,636,RC,J1885,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,0.74,100,,,fee schedule,100% of bcbs custom fee schedule,0.74,100,,,fee schedule,100% of bcbs custom fee schedule,0.82,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
METHYLPREDNISOL INJ 125MG,43601522,CDM,636,RC,J2919,HCPCS,outpatient,25,UN,47,28.20,,28.2,60,,22.56,percent of total billed charges,60% of total billed charges,22.56,48,,18.048,percent of total billed charges,48% of total billed charges,23.5,50,,18.8,percent of total billed charges,50% of total billed charges,23.5,50,,18.8,percent of total billed charges,50% of total billed charges,23.5,50,,18.8,percent of total billed charges,50% of total billed charges,23.5,50,,18.8,percent of total billed charges,50% of total billed charges,32.9,70,,26.32,percent of total billed charges,70% of total billed charges,22.79,48.48,,18.232,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,22.79,48.48,,18.232,percent of total billed charges,48.48% of total billed charges,32.9,70,,26.32,percent of total billed charges,70% of total billed charges,32.9,70,,26.32,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,22.79,48.48,,18.232,percent of total billed charges,48.48% of total billed charges,42.3,90,,33.84,percent of total billed charges,90% of total billed charges,22.79,90,
NOC^ MOXIFLOXACIN 0.5% DRP,,,259,RC,J3490,HCPCS,outpatient,1,UN,327,196.20,,196.2,60,,156.96,percent of total billed charges,60% of total billed charges,156.96,48,,125.568,percent of total billed charges,48% of total billed charges,163.5,50,,130.8,percent of total billed charges,50% of total billed charges,163.5,50,,130.8,percent of total billed charges,50% of total billed charges,163.5,50,,130.8,percent of total billed charges,50% of total billed charges,163.5,50,,130.8,percent of total billed charges,50% of total billed charges,228.9,70,,183.12,percent of total billed charges,70% of total billed charges,158.53,48.48,,126.824,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,158.53,48.48,,126.824,percent of total billed charges,48.48% of total billed charges,228.9,70,,183.12,percent of total billed charges,70% of total billed charges,228.9,70,,183.12,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,158.53,48.48,,126.824,percent of total billed charges,48.48% of total billed charges,294.3,90,,235.44,percent of total billed charges,90% of total billed charges,48.48,294.3,
MIDAZOLAM  INJ 5MG/ML,,,250,RC,J2250,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,0.14,100,,,fee schedule,100% of bcbs custom fee schedule,0.14,100,,,fee schedule,100% of bcbs custom fee schedule,0.16,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
TOBRAMYCIN INJ [40 MG/ML],,,259,RC,J3260,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,3.84,100,,,fee schedule,100% of bcbs custom fee schedule,3.84,100,,,fee schedule,100% of bcbs custom fee schedule,4.26,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
NOC^ TOBRAMYCIN/ DEX DRP [EYE],,,259,RC,J3490,HCPCS,outpatient,1,UN,161,96.60,,96.6,60,,77.28,percent of total billed charges,60% of total billed charges,77.28,48,,61.824,percent of total billed charges,48% of total billed charges,80.5,50,,64.4,percent of total billed charges,50% of total billed charges,80.5,50,,64.4,percent of total billed charges,50% of total billed charges,80.5,50,,64.4,percent of total billed charges,50% of total billed charges,80.5,50,,64.4,percent of total billed charges,50% of total billed charges,112.7,70,,90.16,percent of total billed charges,70% of total billed charges,78.05,48.48,,62.44,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,78.05,48.48,,62.44,percent of total billed charges,48.48% of total billed charges,112.7,70,,90.16,percent of total billed charges,70% of total billed charges,112.7,70,,90.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,78.05,48.48,,62.44,percent of total billed charges,48.48% of total billed charges,144.9,90,,115.92,percent of total billed charges,90% of total billed charges,48.48,144.9,
WELCHOL TAB 625MG,,,259,RC,,,outpatient,,,16,9.60,,9.6,60,,7.68,percent of total billed charges,60% of total billed charges,7.68,48,,6.144,percent of total billed charges,48% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,11.2,70,,8.96,percent of total billed charges,70% of total billed charges,7.76,48.48,,6.208,percent of total billed charges,48.48% of total billed charges,7.76,48.48,,6.208,percent of total billed charges,48.48% of total billed charges,7.76,48.48,,6.208,percent of total billed charges,48.48% of total billed charges,11.2,70,,8.96,percent of total billed charges,70% of total billed charges,11.2,70,,8.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,7.76,48.48,,6.208,percent of total billed charges,48.48% of total billed charges,14.4,90,,11.52,percent of total billed charges,90% of total billed charges,7.76,90,
NOC^ BAL PERU/ TRYP/ CAS OIL O,,,259,RC,J3490,HCPCS,outpatient,1,UN,292,175.20,,175.2,60,,140.16,percent of total billed charges,60% of total billed charges,140.16,48,,112.128,percent of total billed charges,48% of total billed charges,146,50,,116.8,percent of total billed charges,50% of total billed charges,146,50,,116.8,percent of total billed charges,50% of total billed charges,146,50,,116.8,percent of total billed charges,50% of total billed charges,146,50,,116.8,percent of total billed charges,50% of total billed charges,204.4,70,,163.52,percent of total billed charges,70% of total billed charges,141.56,48.48,,113.248,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,141.56,48.48,,113.248,percent of total billed charges,48.48% of total billed charges,204.4,70,,163.52,percent of total billed charges,70% of total billed charges,204.4,70,,163.52,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,141.56,48.48,,113.248,percent of total billed charges,48.48% of total billed charges,262.8,90,,210.24,percent of total billed charges,90% of total billed charges,48.48,262.8,
NOC^ LIDOCAINE/ EPI 1% INJ,,,250,RC,J3490,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
NOC^ LIDOCAINE/ EPI 2% INJ,,,250,RC,J3490,HCPCS,outpatient,1,UN,76,45.60,,45.6,60,,36.48,percent of total billed charges,60% of total billed charges,36.48,48,,29.184,percent of total billed charges,48% of total billed charges,38,50,,30.4,percent of total billed charges,50% of total billed charges,38,50,,30.4,percent of total billed charges,50% of total billed charges,38,50,,30.4,percent of total billed charges,50% of total billed charges,38,50,,30.4,percent of total billed charges,50% of total billed charges,53.2,70,,42.56,percent of total billed charges,70% of total billed charges,36.84,48.48,,29.472,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,36.84,48.48,,29.472,percent of total billed charges,48.48% of total billed charges,53.2,70,,42.56,percent of total billed charges,70% of total billed charges,53.2,70,,42.56,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,36.84,48.48,,29.472,percent of total billed charges,48.48% of total billed charges,68.4,90,,54.72,percent of total billed charges,90% of total billed charges,36.84,90,
NOC^ LIDOCAINE 2% INJ,,,636,RC,J3490,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
LIDOCAINE 2% JELLY [6 ML],,,259,RC,,,outpatient,,,29,17.40,,17.4,60,,13.92,percent of total billed charges,60% of total billed charges,13.92,48,,11.136,percent of total billed charges,48% of total billed charges,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,20.3,70,,16.24,percent of total billed charges,70% of total billed charges,14.06,48.48,,11.248,percent of total billed charges,48.48% of total billed charges,14.06,48.48,,11.248,percent of total billed charges,48.48% of total billed charges,14.06,48.48,,11.248,percent of total billed charges,48.48% of total billed charges,20.3,70,,16.24,percent of total billed charges,70% of total billed charges,20.3,70,,16.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,14.06,48.48,,11.248,percent of total billed charges,48.48% of total billed charges,26.1,90,,20.88,percent of total billed charges,90% of total billed charges,14.06,90,
NOC^ LATANOPROST DRP,,,259,RC,J3490,HCPCS,outpatient,1,UN,393,235.80,,235.8,60,,188.64,percent of total billed charges,60% of total billed charges,188.64,48,,150.912,percent of total billed charges,48% of total billed charges,196.5,50,,157.2,percent of total billed charges,50% of total billed charges,196.5,50,,157.2,percent of total billed charges,50% of total billed charges,196.5,50,,157.2,percent of total billed charges,50% of total billed charges,196.5,50,,157.2,percent of total billed charges,50% of total billed charges,275.1,70,,220.08,percent of total billed charges,70% of total billed charges,190.53,48.48,,152.424,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,190.53,48.48,,152.424,percent of total billed charges,48.48% of total billed charges,275.1,70,,220.08,percent of total billed charges,70% of total billed charges,275.1,70,,220.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,190.53,48.48,,152.424,percent of total billed charges,48.48% of total billed charges,353.7,90,,282.96,percent of total billed charges,90% of total billed charges,48.48,353.7,
NOC^ LIDOCAINE 1% INJ,,,250,RC,J3490,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
LEVALBUTEROL NEB 0.31MG,,,250,RC,J7614,HCPCS,outpatient,1,UN,27,16.20,,16.2,60,,12.96,percent of total billed charges,60% of total billed charges,12.96,48,,10.368,percent of total billed charges,48% of total billed charges,0.07,100,,,fee schedule,100% of bcbs custom fee schedule,0.07,100,,,fee schedule,100% of bcbs custom fee schedule,0.08,111,,,fee schedule,111% of bcbs custom fee schedule,13.5,50,,10.8,percent of total billed charges,50% of total billed charges,18.9,70,,15.12,percent of total billed charges,70% of total billed charges,13.09,48.48,,10.472,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,13.09,48.48,,10.472,percent of total billed charges,48.48% of total billed charges,18.9,70,,15.12,percent of total billed charges,70% of total billed charges,18.9,70,,15.12,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,13.09,48.48,,10.472,percent of total billed charges,48.48% of total billed charges,24.3,90,,19.44,percent of total billed charges,90% of total billed charges,13.09,90,
LEVALBUTEROL NEB 1.25 MG,,,250,RC,J7614,HCPCS,outpatient,1,UN,27,16.20,,16.2,60,,12.96,percent of total billed charges,60% of total billed charges,12.96,48,,10.368,percent of total billed charges,48% of total billed charges,0.07,100,,,fee schedule,100% of bcbs custom fee schedule,0.07,100,,,fee schedule,100% of bcbs custom fee schedule,0.08,111,,,fee schedule,111% of bcbs custom fee schedule,13.5,50,,10.8,percent of total billed charges,50% of total billed charges,18.9,70,,15.12,percent of total billed charges,70% of total billed charges,13.09,48.48,,10.472,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,13.09,48.48,,10.472,percent of total billed charges,48.48% of total billed charges,18.9,70,,15.12,percent of total billed charges,70% of total billed charges,18.9,70,,15.12,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,13.09,48.48,,10.472,percent of total billed charges,48.48% of total billed charges,24.3,90,,19.44,percent of total billed charges,90% of total billed charges,13.09,90,
LEVALBUTEROL NEB 0.63 MG,,,250,RC,J7614,HCPCS,outpatient,1,UN,27,16.20,,16.2,60,,12.96,percent of total billed charges,60% of total billed charges,12.96,48,,10.368,percent of total billed charges,48% of total billed charges,0.07,100,,,fee schedule,100% of bcbs custom fee schedule,0.07,100,,,fee schedule,100% of bcbs custom fee schedule,0.08,111,,,fee schedule,111% of bcbs custom fee schedule,13.5,50,,10.8,percent of total billed charges,50% of total billed charges,18.9,70,,15.12,percent of total billed charges,70% of total billed charges,13.09,48.48,,10.472,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,13.09,48.48,,10.472,percent of total billed charges,48.48% of total billed charges,18.9,70,,15.12,percent of total billed charges,70% of total billed charges,18.9,70,,15.12,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,13.09,48.48,,10.472,percent of total billed charges,48.48% of total billed charges,24.3,90,,19.44,percent of total billed charges,90% of total billed charges,13.09,90,
TRIAMCINOLONE OINT 80 GM,,,259,RC,,,outpatient,,,51,30.60,,30.6,60,,24.48,percent of total billed charges,60% of total billed charges,24.48,48,,19.584,percent of total billed charges,48% of total billed charges,25.5,50,,20.4,percent of total billed charges,50% of total billed charges,25.5,50,,20.4,percent of total billed charges,50% of total billed charges,25.5,50,,20.4,percent of total billed charges,50% of total billed charges,25.5,50,,20.4,percent of total billed charges,50% of total billed charges,35.7,70,,28.56,percent of total billed charges,70% of total billed charges,24.72,48.48,,19.776,percent of total billed charges,48.48% of total billed charges,24.72,48.48,,19.776,percent of total billed charges,48.48% of total billed charges,24.72,48.48,,19.776,percent of total billed charges,48.48% of total billed charges,35.7,70,,28.56,percent of total billed charges,70% of total billed charges,35.7,70,,28.56,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,24.72,48.48,,19.776,percent of total billed charges,48.48% of total billed charges,45.9,90,,36.72,percent of total billed charges,90% of total billed charges,24.72,90,
TRIAMCINOLONE OINT .1% 16 OZ,,,259,RC,,,outpatient,,,166,99.60,,99.6,60,,79.68,percent of total billed charges,60% of total billed charges,79.68,48,,63.744,percent of total billed charges,48% of total billed charges,83,50,,66.4,percent of total billed charges,50% of total billed charges,83,50,,66.4,percent of total billed charges,50% of total billed charges,83,50,,66.4,percent of total billed charges,50% of total billed charges,83,50,,66.4,percent of total billed charges,50% of total billed charges,116.2,70,,92.96,percent of total billed charges,70% of total billed charges,80.48,48.48,,64.384,percent of total billed charges,48.48% of total billed charges,80.48,48.48,,64.384,percent of total billed charges,48.48% of total billed charges,80.48,48.48,,64.384,percent of total billed charges,48.48% of total billed charges,116.2,70,,92.96,percent of total billed charges,70% of total billed charges,116.2,70,,92.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,80.48,48.48,,64.384,percent of total billed charges,48.48% of total billed charges,149.4,90,,119.52,percent of total billed charges,90% of total billed charges,48.48,149.4,
NOC^ KETOTIFEN DRP,,,259,RC,J3490,HCPCS,outpatient,1,UN,49,29.40,,29.4,60,,23.52,percent of total billed charges,60% of total billed charges,23.52,48,,18.816,percent of total billed charges,48% of total billed charges,24.5,50,,19.6,percent of total billed charges,50% of total billed charges,24.5,50,,19.6,percent of total billed charges,50% of total billed charges,24.5,50,,19.6,percent of total billed charges,50% of total billed charges,24.5,50,,19.6,percent of total billed charges,50% of total billed charges,34.3,70,,27.44,percent of total billed charges,70% of total billed charges,23.76,48.48,,19.008,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,23.76,48.48,,19.008,percent of total billed charges,48.48% of total billed charges,34.3,70,,27.44,percent of total billed charges,70% of total billed charges,34.3,70,,27.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,23.76,48.48,,19.008,percent of total billed charges,48.48% of total billed charges,44.1,90,,35.28,percent of total billed charges,90% of total billed charges,23.76,90,
RANITIDINE INJ 50 MG/2 ML,,,636,RC,J2780,HCPCS,outpatient,1,UN,72,43.20,,43.2,60,,34.56,percent of total billed charges,60% of total billed charges,34.56,48,,27.648,percent of total billed charges,48% of total billed charges,3.64,100,,,fee schedule,100% of bcbs custom fee schedule,3.64,100,,,fee schedule,100% of bcbs custom fee schedule,4.04,111,,,fee schedule,111% of bcbs custom fee schedule,36,50,,28.8,percent of total billed charges,50% of total billed charges,50.4,70,,40.32,percent of total billed charges,70% of total billed charges,34.91,48.48,,27.928,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,34.91,48.48,,27.928,percent of total billed charges,48.48% of total billed charges,50.4,70,,40.32,percent of total billed charges,70% of total billed charges,50.4,70,,40.32,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,34.91,48.48,,27.928,percent of total billed charges,48.48% of total billed charges,64.8,90,,51.84,percent of total billed charges,90% of total billed charges,34.91,90,
NOC^ EZETIMIBE TAB [10 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,50,30.00,,30,60,,24,percent of total billed charges,60% of total billed charges,24,48,,19.2,percent of total billed charges,48% of total billed charges,25,50,,20,percent of total billed charges,50% of total billed charges,25,50,,20,percent of total billed charges,50% of total billed charges,25,50,,20,percent of total billed charges,50% of total billed charges,25,50,,20,percent of total billed charges,50% of total billed charges,35,70,,28,percent of total billed charges,70% of total billed charges,24.24,48.48,,19.392,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,24.24,48.48,,19.392,percent of total billed charges,48.48% of total billed charges,35,70,,28,percent of total billed charges,70% of total billed charges,35,70,,28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,24.24,48.48,,19.392,percent of total billed charges,48.48% of total billed charges,45,90,,36,percent of total billed charges,90% of total billed charges,24.24,90,
NOC^ AZITHROMYCIN SUS [100 MG/,,,259,RC,J3490,HCPCS,outpatient,1,UN,140,84.00,,84,60,,67.2,percent of total billed charges,60% of total billed charges,67.2,48,,53.76,percent of total billed charges,48% of total billed charges,70,50,,56,percent of total billed charges,50% of total billed charges,70,50,,56,percent of total billed charges,50% of total billed charges,70,50,,56,percent of total billed charges,50% of total billed charges,70,50,,56,percent of total billed charges,50% of total billed charges,98,70,,78.4,percent of total billed charges,70% of total billed charges,67.87,48.48,,54.296,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,67.87,48.48,,54.296,percent of total billed charges,48.48% of total billed charges,98,70,,78.4,percent of total billed charges,70% of total billed charges,98,70,,78.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,67.87,48.48,,54.296,percent of total billed charges,48.48% of total billed charges,126,90,,100.8,percent of total billed charges,90% of total billed charges,48.48,126,
PIPERACILLIN/ TAZO 2.25GM,,,636,RC,J2543,HCPCS,outpatient,1,UN,33,19.80,,19.8,60,,15.84,percent of total billed charges,60% of total billed charges,15.84,48,,12.672,percent of total billed charges,48% of total billed charges,1.82,100,,,fee schedule,100% of bcbs custom fee schedule,1.82,100,,,fee schedule,100% of bcbs custom fee schedule,2.02,111,,,fee schedule,111% of bcbs custom fee schedule,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,23.1,70,,18.48,percent of total billed charges,70% of total billed charges,16,48.48,,12.8,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,16,48.48,,12.8,percent of total billed charges,48.48% of total billed charges,23.1,70,,18.48,percent of total billed charges,70% of total billed charges,23.1,70,,18.48,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,16,48.48,,12.8,percent of total billed charges,48.48% of total billed charges,29.7,90,,23.76,percent of total billed charges,90% of total billed charges,16,90,
NOC^ ACYCLOVIR TAB 400 MG,,,259,RC,J8499,HCPCS,outpatient,1,UN,15,9.00,,9,60,,7.2,percent of total billed charges,60% of total billed charges,7.2,48,,5.76,percent of total billed charges,48% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,13.5,90,,10.8,percent of total billed charges,90% of total billed charges,7.27,90,
RANITIDINE/ NACL PREMIX [,,,250,RC,J2780,HCPCS,outpatient,1,UN,60,36.00,,36,60,,28.8,percent of total billed charges,60% of total billed charges,28.8,48,,23.04,percent of total billed charges,48% of total billed charges,3.64,100,,,fee schedule,100% of bcbs custom fee schedule,3.64,100,,,fee schedule,100% of bcbs custom fee schedule,4.04,111,,,fee schedule,111% of bcbs custom fee schedule,30,50,,24,percent of total billed charges,50% of total billed charges,42,70,,33.6,percent of total billed charges,70% of total billed charges,29.09,48.48,,23.272,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,29.09,48.48,,23.272,percent of total billed charges,48.48% of total billed charges,42,70,,33.6,percent of total billed charges,70% of total billed charges,42,70,,33.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,29.09,48.48,,23.272,percent of total billed charges,48.48% of total billed charges,54,90,,43.2,percent of total billed charges,90% of total billed charges,29.09,90,
NOC^ ACYCLOVIR 5% OINT 2 GM,,,259,RC,J3490,HCPCS,outpatient,1,UN,562,337.20,,337.2,60,,269.76,percent of total billed charges,60% of total billed charges,269.76,48,,215.808,percent of total billed charges,48% of total billed charges,281,50,,224.8,percent of total billed charges,50% of total billed charges,281,50,,224.8,percent of total billed charges,50% of total billed charges,281,50,,224.8,percent of total billed charges,50% of total billed charges,281,50,,224.8,percent of total billed charges,50% of total billed charges,393.4,70,,314.72,percent of total billed charges,70% of total billed charges,272.46,48.48,,217.968,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,272.46,48.48,,217.968,percent of total billed charges,48.48% of total billed charges,393.4,70,,314.72,percent of total billed charges,70% of total billed charges,393.4,70,,314.72,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,272.46,48.48,,217.968,percent of total billed charges,48.48% of total billed charges,505.8,90,,404.64,percent of total billed charges,90% of total billed charges,48.48,505.8,
KETOROLAC INJ 60 MG/2ML,43601515,CDM,636,RC,J1885,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,0.74,100,,,fee schedule,100% of bcbs custom fee schedule,0.74,100,,,fee schedule,100% of bcbs custom fee schedule,0.82,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
NOC^ ACYCLOVIR 5% OIN 15 GM,,,259,RC,J3490,HCPCS,outpatient,1,UN,768,460.80,,460.8,60,,368.64,percent of total billed charges,60% of total billed charges,368.64,48,,294.912,percent of total billed charges,48% of total billed charges,384,50,,307.2,percent of total billed charges,50% of total billed charges,384,50,,307.2,percent of total billed charges,50% of total billed charges,384,50,,307.2,percent of total billed charges,50% of total billed charges,384,50,,307.2,percent of total billed charges,50% of total billed charges,537.6,70,,430.08,percent of total billed charges,70% of total billed charges,372.33,48.48,,297.864,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,372.33,48.48,,297.864,percent of total billed charges,48.48% of total billed charges,537.6,70,,430.08,percent of total billed charges,70% of total billed charges,537.6,70,,430.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,372.33,48.48,,297.864,percent of total billed charges,48.48% of total billed charges,691.2,90,,552.96,percent of total billed charges,90% of total billed charges,48.48,691.2,
NOC^ TRIAMCINOLONE 0.1% OIN [1,,,259,RC,J3490,HCPCS,outpatient,1,UN,23,13.80,,13.8,60,,11.04,percent of total billed charges,60% of total billed charges,11.04,48,,8.832,percent of total billed charges,48% of total billed charges,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,16.1,70,,12.88,percent of total billed charges,70% of total billed charges,11.15,48.48,,8.92,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,11.15,48.48,,8.92,percent of total billed charges,48.48% of total billed charges,16.1,70,,12.88,percent of total billed charges,70% of total billed charges,16.1,70,,12.88,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,11.15,48.48,,8.92,percent of total billed charges,48.48% of total billed charges,20.7,90,,16.56,percent of total billed charges,90% of total billed charges,11.15,90,
NOC^ TRIAMCINOLONE 0.1% CRM 15,,,259,RC,J3490,HCPCS,outpatient,1,UN,23,13.80,,13.8,60,,11.04,percent of total billed charges,60% of total billed charges,11.04,48,,8.832,percent of total billed charges,48% of total billed charges,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,16.1,70,,12.88,percent of total billed charges,70% of total billed charges,11.15,48.48,,8.92,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,11.15,48.48,,8.92,percent of total billed charges,48.48% of total billed charges,16.1,70,,12.88,percent of total billed charges,70% of total billed charges,16.1,70,,12.88,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,11.15,48.48,,8.92,percent of total billed charges,48.48% of total billed charges,20.7,90,,16.56,percent of total billed charges,90% of total billed charges,11.15,90,
CEFTRIAXONE INJ 500 MG,43601503,CDM,636,RC,J0696,HCPCS,outpatient,2,UN,50,30.00,,30,60,,24,percent of total billed charges,60% of total billed charges,24,48,,19.2,percent of total billed charges,48% of total billed charges,0.69,100,,,fee schedule,100% of bcbs custom fee schedule,0.69,100,,,fee schedule,100% of bcbs custom fee schedule,0.77,111,,,fee schedule,111% of bcbs custom fee schedule,25,50,,20,percent of total billed charges,50% of total billed charges,35,70,,28,percent of total billed charges,70% of total billed charges,24.24,48.48,,19.392,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,24.24,48.48,,19.392,percent of total billed charges,48.48% of total billed charges,35,70,,28,percent of total billed charges,70% of total billed charges,35,70,,28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,24.24,48.48,,19.392,percent of total billed charges,48.48% of total billed charges,45,90,,36,percent of total billed charges,90% of total billed charges,24.24,90,
LINEZOLID TAB [600 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,506,303.60,,303.6,60,,242.88,percent of total billed charges,60% of total billed charges,242.88,48,,194.304,percent of total billed charges,48% of total billed charges,253,50,,202.4,percent of total billed charges,50% of total billed charges,253,50,,202.4,percent of total billed charges,50% of total billed charges,253,50,,202.4,percent of total billed charges,50% of total billed charges,253,50,,202.4,percent of total billed charges,50% of total billed charges,354.2,70,,283.36,percent of total billed charges,70% of total billed charges,245.31,48.48,,196.248,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,245.31,48.48,,196.248,percent of total billed charges,48.48% of total billed charges,354.2,70,,283.36,percent of total billed charges,70% of total billed charges,354.2,70,,283.36,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,245.31,48.48,,196.248,percent of total billed charges,48.48% of total billed charges,455.4,90,,364.32,percent of total billed charges,90% of total billed charges,48.48,455.4,
CEFTRIAXONE INJ 250 MG,43601503,CDM,636,RC,J0696,HCPCS,outpatient,1,UN,25,15.00,,15,60,,12,percent of total billed charges,60% of total billed charges,12,48,,9.6,percent of total billed charges,48% of total billed charges,0.69,100,,,fee schedule,100% of bcbs custom fee schedule,0.69,100,,,fee schedule,100% of bcbs custom fee schedule,0.77,111,,,fee schedule,111% of bcbs custom fee schedule,12.5,50,,10,percent of total billed charges,50% of total billed charges,17.5,70,,14,percent of total billed charges,70% of total billed charges,12.12,48.48,,9.696,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,12.12,48.48,,9.696,percent of total billed charges,48.48% of total billed charges,17.5,70,,14,percent of total billed charges,70% of total billed charges,17.5,70,,14,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,12.12,48.48,,9.696,percent of total billed charges,48.48% of total billed charges,22.5,90,,18,percent of total billed charges,90% of total billed charges,12.12,90,
NOC^ SOLIFENACIN TAB [5 MG),,,259,RC,J8499,HCPCS,outpatient,1,UN,56,33.60,,33.6,60,,26.88,percent of total billed charges,60% of total billed charges,26.88,48,,21.504,percent of total billed charges,48% of total billed charges,28,50,,22.4,percent of total billed charges,50% of total billed charges,28,50,,22.4,percent of total billed charges,50% of total billed charges,28,50,,22.4,percent of total billed charges,50% of total billed charges,28,50,,22.4,percent of total billed charges,50% of total billed charges,39.2,70,,31.36,percent of total billed charges,70% of total billed charges,27.15,48.48,,21.72,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,27.15,48.48,,21.72,percent of total billed charges,48.48% of total billed charges,39.2,70,,31.36,percent of total billed charges,70% of total billed charges,39.2,70,,31.36,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,27.15,48.48,,21.72,percent of total billed charges,48.48% of total billed charges,50.4,90,,40.32,percent of total billed charges,90% of total billed charges,27.15,90,
NOC^ VECURONIUM INJ [10 MG],,,250,RC,J3490,HCPCS,outpatient,1,UN,25,15.00,,15,60,,12,percent of total billed charges,60% of total billed charges,12,48,,9.6,percent of total billed charges,48% of total billed charges,12.5,50,,10,percent of total billed charges,50% of total billed charges,12.5,50,,10,percent of total billed charges,50% of total billed charges,12.5,50,,10,percent of total billed charges,50% of total billed charges,12.5,50,,10,percent of total billed charges,50% of total billed charges,17.5,70,,14,percent of total billed charges,70% of total billed charges,12.12,48.48,,9.696,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,12.12,48.48,,9.696,percent of total billed charges,48.48% of total billed charges,17.5,70,,14,percent of total billed charges,70% of total billed charges,17.5,70,,14,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,12.12,48.48,,9.696,percent of total billed charges,48.48% of total billed charges,22.5,90,,18,percent of total billed charges,90% of total billed charges,12.12,90,
ZOSTER VACC  INJ,,,636,RC,90736,HCPCS,outpatient,1,UN,511,306.60,,306.6,60,,245.28,percent of total billed charges,60% of total billed charges,245.28,48,,196.224,percent of total billed charges,48% of total billed charges,242.44,100,,,fee schedule,100% of bcbs custom fee schedule,242.44,100,,,fee schedule,100% of bcbs custom fee schedule,269.11,111,,,fee schedule,111% of bcbs custom fee schedule,255.5,50,,204.4,percent of total billed charges,50% of total billed charges,357.7,70,,286.16,percent of total billed charges,70% of total billed charges,247.73,48.48,,198.184,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,247.73,48.48,,198.184,percent of total billed charges,48.48% of total billed charges,357.7,70,,286.16,percent of total billed charges,70% of total billed charges,357.7,70,,286.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,247.73,48.48,,198.184,percent of total billed charges,48.48% of total billed charges,459.9,90,,367.92,percent of total billed charges,90% of total billed charges,48.48,459.9,
NOC^ NITROFURANTOIN CAP [100 M,,,259,RC,J8499,HCPCS,outpatient,1,UN,15,9.00,,9,60,,7.2,percent of total billed charges,60% of total billed charges,7.2,48,,5.76,percent of total billed charges,48% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,13.5,90,,10.8,percent of total billed charges,90% of total billed charges,7.27,90,
NOC^ AZITHROMYCIN SUS [200 MG/,,,259,RC,J3490,HCPCS,outpatient,1,UN,140,84.00,,84,60,,67.2,percent of total billed charges,60% of total billed charges,67.2,48,,53.76,percent of total billed charges,48% of total billed charges,70,50,,56,percent of total billed charges,50% of total billed charges,70,50,,56,percent of total billed charges,50% of total billed charges,70,50,,56,percent of total billed charges,50% of total billed charges,70,50,,56,percent of total billed charges,50% of total billed charges,98,70,,78.4,percent of total billed charges,70% of total billed charges,67.87,48.48,,54.296,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,67.87,48.48,,54.296,percent of total billed charges,48.48% of total billed charges,98,70,,78.4,percent of total billed charges,70% of total billed charges,98,70,,78.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,67.87,48.48,,54.296,percent of total billed charges,48.48% of total billed charges,126,90,,100.8,percent of total billed charges,90% of total billed charges,48.48,126,
NOC^ ONDANSETRON TAB 4 MG,,,259,RC,J8597,HCPCS,outpatient,1,UN,100,60.00,,60,60,,48,percent of total billed charges,60% of total billed charges,48,48,,38.4,percent of total billed charges,48% of total billed charges,50,50,,40,percent of total billed charges,50% of total billed charges,50,50,,40,percent of total billed charges,50% of total billed charges,50,50,,40,percent of total billed charges,50% of total billed charges,50,50,,40,percent of total billed charges,50% of total billed charges,70,70,,56,percent of total billed charges,70% of total billed charges,48.48,48.48,,38.784,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,48.48,48.48,,38.784,percent of total billed charges,48.48% of total billed charges,70,70,,56,percent of total billed charges,70% of total billed charges,70,70,,56,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,48.48,48.48,,38.784,percent of total billed charges,48.48% of total billed charges,90,90,,72,percent of total billed charges,90% of total billed charges,48.48,90,
NOC^ CETIRIZINE TAB [10 MG],,,259,RC,A9150,HCPCS,outpatient,1,UN,10,6.00,,6,60,,4.8,percent of total billed charges,60% of total billed charges,4.8,48,,3.84,percent of total billed charges,48% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,7,70,,5.6,percent of total billed charges,70% of total billed charges,4.85,48.48,,3.88,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,4.85,48.48,,3.88,percent of total billed charges,48.48% of total billed charges,7,70,,5.6,percent of total billed charges,70% of total billed charges,7,70,,5.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,4.85,48.48,,3.88,percent of total billed charges,48.48% of total billed charges,9,90,,7.2,percent of total billed charges,90% of total billed charges,4.85,90,
NOC^ OLANZAPINE TAB [5 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,44,26.40,,26.4,60,,21.12,percent of total billed charges,60% of total billed charges,21.12,48,,16.896,percent of total billed charges,48% of total billed charges,22,50,,17.6,percent of total billed charges,50% of total billed charges,22,50,,17.6,percent of total billed charges,50% of total billed charges,22,50,,17.6,percent of total billed charges,50% of total billed charges,22,50,,17.6,percent of total billed charges,50% of total billed charges,30.8,70,,24.64,percent of total billed charges,70% of total billed charges,21.33,48.48,,17.064,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,21.33,48.48,,17.064,percent of total billed charges,48.48% of total billed charges,30.8,70,,24.64,percent of total billed charges,70% of total billed charges,30.8,70,,24.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,21.33,48.48,,17.064,percent of total billed charges,48.48% of total billed charges,39.6,90,,31.68,percent of total billed charges,90% of total billed charges,21.33,90,
LIDOCAINE 2% SYR [100 MG/5ML],,,250,RC,J2001,HCPCS,outpatient,1,UN,28,16.80,,16.8,60,,13.44,percent of total billed charges,60% of total billed charges,13.44,48,,10.752,percent of total billed charges,48% of total billed charges,0.02,100,,,fee schedule,100% of bcbs custom fee schedule,0.02,100,,,fee schedule,100% of bcbs custom fee schedule,0.02,111,,,fee schedule,111% of bcbs custom fee schedule,14,50,,11.2,percent of total billed charges,50% of total billed charges,19.6,70,,15.68,percent of total billed charges,70% of total billed charges,13.57,48.48,,10.856,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,13.57,48.48,,10.856,percent of total billed charges,48.48% of total billed charges,19.6,70,,15.68,percent of total billed charges,70% of total billed charges,19.6,70,,15.68,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,13.57,48.48,,10.856,percent of total billed charges,48.48% of total billed charges,25.2,90,,20.16,percent of total billed charges,90% of total billed charges,13.57,90,
LINEZOLID/D5W PREMIX [600,,,636,RC,J2020,HCPCS,outpatient,3,UN,313.02,187.81,,187.81,60,,150.248,percent of total billed charges,60% of total billed charges,150.25,48,,120.2,percent of total billed charges,48% of total billed charges,8.26,100,,,fee schedule,100% of bcbs custom fee schedule,8.26,100,,,fee schedule,100% of bcbs custom fee schedule,9.17,111,,,fee schedule,111% of bcbs custom fee schedule,156.51,50,,125.208,percent of total billed charges,50% of total billed charges,219.11,70,,175.288,percent of total billed charges,70% of total billed charges,151.75,48.48,,121.4,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,151.75,48.48,,121.4,percent of total billed charges,48.48% of total billed charges,219.11,70,,175.288,percent of total billed charges,70% of total billed charges,219.11,70,,175.288,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,151.75,48.48,,121.4,percent of total billed charges,48.48% of total billed charges,281.72,90,,225.376,percent of total billed charges,90% of total billed charges,48.48,281.72,
ALTEPLASE RECOMB 100 MG,,,636,RC,J2997,HCPCS,outpatient,1,UN,21121,12672.60,,12672.6,60,,10138.08,percent of total billed charges,60% of total billed charges,10138.08,48,,8110.464,percent of total billed charges,48% of total billed charges,95.87,100,,,fee schedule,100% of bcbs custom fee schedule,95.87,100,,,fee schedule,100% of bcbs custom fee schedule,106.42,111,,,fee schedule,111% of bcbs custom fee schedule,10560.5,50,,8448.4,percent of total billed charges,50% of total billed charges,14784.7,70,,11827.76,percent of total billed charges,70% of total billed charges,10239.46,48.48,,8191.568,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,10239.46,48.48,,8191.568,percent of total billed charges,48.48% of total billed charges,14784.7,70,,11827.76,percent of total billed charges,70% of total billed charges,14784.7,70,,11827.76,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,10239.46,48.48,,8191.568,percent of total billed charges,48.48% of total billed charges,19008.9,90,,15207.12,percent of total billed charges,90% of total billed charges,48.48,19008.9,
AZITHROMYCIN INJ [500 MG],,,636,RC,J0456,HCPCS,outpatient,1,UN,37,22.20,,22.2,60,,17.76,percent of total billed charges,60% of total billed charges,17.76,48,,14.208,percent of total billed charges,48% of total billed charges,4.43,100,,,fee schedule,100% of bcbs custom fee schedule,4.43,100,,,fee schedule,100% of bcbs custom fee schedule,4.92,111,,,fee schedule,111% of bcbs custom fee schedule,18.5,50,,14.8,percent of total billed charges,50% of total billed charges,25.9,70,,20.72,percent of total billed charges,70% of total billed charges,17.94,48.48,,14.352,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,17.94,48.48,,14.352,percent of total billed charges,48.48% of total billed charges,25.9,70,,20.72,percent of total billed charges,70% of total billed charges,25.9,70,,20.72,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,17.94,48.48,,14.352,percent of total billed charges,48.48% of total billed charges,33.3,90,,26.64,percent of total billed charges,90% of total billed charges,17.94,90,
NOC^ LIDOCAINE 5% PATCH,,,259,RC,J3490,HCPCS,outpatient,1,UN,106,63.60,,63.6,60,,50.88,percent of total billed charges,60% of total billed charges,50.88,48,,40.704,percent of total billed charges,48% of total billed charges,53,50,,42.4,percent of total billed charges,50% of total billed charges,53,50,,42.4,percent of total billed charges,50% of total billed charges,53,50,,42.4,percent of total billed charges,50% of total billed charges,53,50,,42.4,percent of total billed charges,50% of total billed charges,74.2,70,,59.36,percent of total billed charges,70% of total billed charges,51.39,48.48,,41.112,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,51.39,48.48,,41.112,percent of total billed charges,48.48% of total billed charges,74.2,70,,59.36,percent of total billed charges,70% of total billed charges,74.2,70,,59.36,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,51.39,48.48,,41.112,percent of total billed charges,48.48% of total billed charges,95.4,90,,76.32,percent of total billed charges,90% of total billed charges,48.48,95.4,
NOC^ AZITHROMYCIN TAB [250 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,17,10.20,,10.2,60,,8.16,percent of total billed charges,60% of total billed charges,8.16,48,,6.528,percent of total billed charges,48% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,11.9,70,,9.52,percent of total billed charges,70% of total billed charges,8.24,48.48,,6.592,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,8.24,48.48,,6.592,percent of total billed charges,48.48% of total billed charges,11.9,70,,9.52,percent of total billed charges,70% of total billed charges,11.9,70,,9.52,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,8.24,48.48,,6.592,percent of total billed charges,48.48% of total billed charges,15.3,90,,12.24,percent of total billed charges,90% of total billed charges,8.24,90,
NOC^ AZITHROMYCIN TAB [500 MG],,,259,RC,J3490,HCPCS,outpatient,1,UN,63,37.80,,37.8,60,,30.24,percent of total billed charges,60% of total billed charges,30.24,48,,24.192,percent of total billed charges,48% of total billed charges,31.5,50,,25.2,percent of total billed charges,50% of total billed charges,31.5,50,,25.2,percent of total billed charges,50% of total billed charges,31.5,50,,25.2,percent of total billed charges,50% of total billed charges,31.5,50,,25.2,percent of total billed charges,50% of total billed charges,44.1,70,,35.28,percent of total billed charges,70% of total billed charges,30.54,48.48,,24.432,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,30.54,48.48,,24.432,percent of total billed charges,48.48% of total billed charges,44.1,70,,35.28,percent of total billed charges,70% of total billed charges,44.1,70,,35.28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,30.54,48.48,,24.432,percent of total billed charges,48.48% of total billed charges,56.7,90,,45.36,percent of total billed charges,90% of total billed charges,30.54,90,
FLUCONAZOLE 200MG/100ML PRMX,,,636,RC,J1450,HCPCS,outpatient,1,UN,44,26.40,,26.4,60,,21.12,percent of total billed charges,60% of total billed charges,21.12,48,,16.896,percent of total billed charges,48% of total billed charges,3.77,100,,,fee schedule,100% of bcbs custom fee schedule,3.77,100,,,fee schedule,100% of bcbs custom fee schedule,4.18,111,,,fee schedule,111% of bcbs custom fee schedule,22,50,,17.6,percent of total billed charges,50% of total billed charges,30.8,70,,24.64,percent of total billed charges,70% of total billed charges,21.33,48.48,,17.064,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,21.33,48.48,,17.064,percent of total billed charges,48.48% of total billed charges,30.8,70,,24.64,percent of total billed charges,70% of total billed charges,30.8,70,,24.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,21.33,48.48,,17.064,percent of total billed charges,48.48% of total billed charges,39.6,90,,31.68,percent of total billed charges,90% of total billed charges,21.33,90,
PIPERACILLIN/ TAZO 3.375G,,,636,RC,J2543,HCPCS,outpatient,3,UN,50.01,30.01,,30.01,60,,24.008,percent of total billed charges,60% of total billed charges,24,48,,19.2,percent of total billed charges,48% of total billed charges,1.82,100,,,fee schedule,100% of bcbs custom fee schedule,1.82,100,,,fee schedule,100% of bcbs custom fee schedule,2.02,111,,,fee schedule,111% of bcbs custom fee schedule,25.01,50,,20.008,percent of total billed charges,50% of total billed charges,35.01,70,,28.008,percent of total billed charges,70% of total billed charges,24.24,48.48,,19.392,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,24.24,48.48,,19.392,percent of total billed charges,48.48% of total billed charges,35.01,70,,28.008,percent of total billed charges,70% of total billed charges,35.01,70,,28.008,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,24.24,48.48,,19.392,percent of total billed charges,48.48% of total billed charges,45.01,90,,36.008,percent of total billed charges,90% of total billed charges,24.24,90,
NOC^ SERTRALINE TAB [100 MG],,,259,RC,J3490,HCPCS,outpatient,1,UN,11,6.60,,6.6,60,,5.28,percent of total billed charges,60% of total billed charges,5.28,48,,4.224,percent of total billed charges,48% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,9.9,90,,7.92,percent of total billed charges,90% of total billed charges,5.33,90,
INS- ASPART INJ [100 UNT/,,,250,RC,J1815,HCPCS,outpatient,1,UN,24,14.40,,14.4,60,,11.52,percent of total billed charges,60% of total billed charges,11.52,48,,9.216,percent of total billed charges,48% of total billed charges,0.96,100,,,fee schedule,100% of bcbs custom fee schedule,0.96,100,,,fee schedule,100% of bcbs custom fee schedule,1.07,111,,,fee schedule,111% of bcbs custom fee schedule,12,50,,9.6,percent of total billed charges,50% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,21.6,90,,17.28,percent of total billed charges,90% of total billed charges,11.64,90,
NOC^ TOBRAMYCIN/ DEX OIN [EYE],,,259,RC,J3490,HCPCS,outpatient,1,UN,488,292.80,,292.8,60,,234.24,percent of total billed charges,60% of total billed charges,234.24,48,,187.392,percent of total billed charges,48% of total billed charges,244,50,,195.2,percent of total billed charges,50% of total billed charges,244,50,,195.2,percent of total billed charges,50% of total billed charges,244,50,,195.2,percent of total billed charges,50% of total billed charges,244,50,,195.2,percent of total billed charges,50% of total billed charges,341.6,70,,273.28,percent of total billed charges,70% of total billed charges,236.58,48.48,,189.264,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,236.58,48.48,,189.264,percent of total billed charges,48.48% of total billed charges,341.6,70,,273.28,percent of total billed charges,70% of total billed charges,341.6,70,,273.28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,236.58,48.48,,189.264,percent of total billed charges,48.48% of total billed charges,439.2,90,,351.36,percent of total billed charges,90% of total billed charges,48.48,439.2,
NOC^ AMLODIPINE TAB [10 MG],,,259,RC,J3490,HCPCS,outpatient,1,UN,10,6.00,,6,60,,4.8,percent of total billed charges,60% of total billed charges,4.8,48,,3.84,percent of total billed charges,48% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,7,70,,5.6,percent of total billed charges,70% of total billed charges,4.85,48.48,,3.88,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,4.85,48.48,,3.88,percent of total billed charges,48.48% of total billed charges,7,70,,5.6,percent of total billed charges,70% of total billed charges,7,70,,5.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,4.85,48.48,,3.88,percent of total billed charges,48.48% of total billed charges,9,90,,7.2,percent of total billed charges,90% of total billed charges,4.85,90,
ONDANSETRON INJ 4 MG/2ML,,,636,RC,J2405,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,0.1,100,,,fee schedule,100% of bcbs custom fee schedule,0.1,100,,,fee schedule,100% of bcbs custom fee schedule,0.11,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
NOC^ SIMVASTATIN TAB [10 MG],,,259,RC,J3490,HCPCS,outpatient,1,UN,12,7.20,,7.2,60,,5.76,percent of total billed charges,60% of total billed charges,5.76,48,,4.608,percent of total billed charges,48% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,8.4,70,,6.72,percent of total billed charges,70% of total billed charges,5.82,48.48,,4.656,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,5.82,48.48,,4.656,percent of total billed charges,48.48% of total billed charges,8.4,70,,6.72,percent of total billed charges,70% of total billed charges,8.4,70,,6.72,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,5.82,48.48,,4.656,percent of total billed charges,48.48% of total billed charges,10.8,90,,8.64,percent of total billed charges,90% of total billed charges,5.82,90,
NOC^ SIMVASTATIN TAB [20 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
NOC^ SIMVASTATIN TAB [40 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
NOC^ ZIPRASIDONE CAP 40 MG,,,250,RC,J8499,HCPCS,outpatient,1,UN,44,26.40,,26.4,60,,21.12,percent of total billed charges,60% of total billed charges,21.12,48,,16.896,percent of total billed charges,48% of total billed charges,22,50,,17.6,percent of total billed charges,50% of total billed charges,22,50,,17.6,percent of total billed charges,50% of total billed charges,22,50,,17.6,percent of total billed charges,50% of total billed charges,22,50,,17.6,percent of total billed charges,50% of total billed charges,30.8,70,,24.64,percent of total billed charges,70% of total billed charges,21.33,48.48,,17.064,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,21.33,48.48,,17.064,percent of total billed charges,48.48% of total billed charges,30.8,70,,24.64,percent of total billed charges,70% of total billed charges,30.8,70,,24.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,21.33,48.48,,17.064,percent of total billed charges,48.48% of total billed charges,39.6,90,,31.68,percent of total billed charges,90% of total billed charges,21.33,90,
NOC^ DIPHEN/LID/MAAL SUSP,,,259,RC,J3490,HCPCS,outpatient,1,UN,37,22.20,,22.2,60,,17.76,percent of total billed charges,60% of total billed charges,17.76,48,,14.208,percent of total billed charges,48% of total billed charges,18.5,50,,14.8,percent of total billed charges,50% of total billed charges,18.5,50,,14.8,percent of total billed charges,50% of total billed charges,18.5,50,,14.8,percent of total billed charges,50% of total billed charges,18.5,50,,14.8,percent of total billed charges,50% of total billed charges,25.9,70,,20.72,percent of total billed charges,70% of total billed charges,17.94,48.48,,14.352,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,17.94,48.48,,14.352,percent of total billed charges,48.48% of total billed charges,25.9,70,,20.72,percent of total billed charges,70% of total billed charges,25.9,70,,20.72,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,17.94,48.48,,14.352,percent of total billed charges,48.48% of total billed charges,33.3,90,,26.64,percent of total billed charges,90% of total billed charges,17.94,90,
NOC^ LEVETIRACETAM TAB 1000 MG,,,259,RC,J8499,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
NOC^ LACOSAMIDE TAB 100 MG,,,259,RC,J8499,HCPCS,outpatient,1,UN,39,23.40,,23.4,60,,18.72,percent of total billed charges,60% of total billed charges,18.72,48,,14.976,percent of total billed charges,48% of total billed charges,19.5,50,,15.6,percent of total billed charges,50% of total billed charges,19.5,50,,15.6,percent of total billed charges,50% of total billed charges,19.5,50,,15.6,percent of total billed charges,50% of total billed charges,19.5,50,,15.6,percent of total billed charges,50% of total billed charges,27.3,70,,21.84,percent of total billed charges,70% of total billed charges,18.91,48.48,,15.128,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,18.91,48.48,,15.128,percent of total billed charges,48.48% of total billed charges,27.3,70,,21.84,percent of total billed charges,70% of total billed charges,27.3,70,,21.84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,18.91,48.48,,15.128,percent of total billed charges,48.48% of total billed charges,35.1,90,,28.08,percent of total billed charges,90% of total billed charges,18.91,90,
TET/DIPTH/PERT VACC 0.5ML,36000022,CDM,636,RC,90715,HCPCS,outpatient,1,UN,115,69.00,,69,60,,55.2,percent of total billed charges,60% of total billed charges,55.2,48,,44.16,percent of total billed charges,48% of total billed charges,37.71,100,,,fee schedule,100% of bcbs custom fee schedule,37.71,100,,,fee schedule,100% of bcbs custom fee schedule,41.86,111,,,fee schedule,111% of bcbs custom fee schedule,57.5,50,,46,percent of total billed charges,50% of total billed charges,80.5,70,,64.4,percent of total billed charges,70% of total billed charges,55.75,48.48,,44.6,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,55.75,48.48,,44.6,percent of total billed charges,48.48% of total billed charges,80.5,70,,64.4,percent of total billed charges,70% of total billed charges,80.5,70,,64.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,55.75,48.48,,44.6,percent of total billed charges,48.48% of total billed charges,103.5,90,,82.8,percent of total billed charges,90% of total billed charges,48.48,103.5,
HEP A&B VACC 1ML,,,636,RC,90636,HCPCS,outpatient,1,UN,216,129.60,,129.6,60,,103.68,percent of total billed charges,60% of total billed charges,103.68,48,,82.944,percent of total billed charges,48% of total billed charges,124.12,100,,,fee schedule,100% of bcbs custom fee schedule,124.12,100,,,fee schedule,100% of bcbs custom fee schedule,137.77,111,,,fee schedule,111% of bcbs custom fee schedule,108,50,,86.4,percent of total billed charges,50% of total billed charges,151.2,70,,120.96,percent of total billed charges,70% of total billed charges,104.72,48.48,,83.776,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,104.72,48.48,,83.776,percent of total billed charges,48.48% of total billed charges,151.2,70,,120.96,percent of total billed charges,70% of total billed charges,151.2,70,,120.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,104.72,48.48,,83.776,percent of total billed charges,48.48% of total billed charges,194.4,90,,155.52,percent of total billed charges,90% of total billed charges,48.48,194.4,
NOC^ PRASUGREL TAB 10 MG,,,259,RC,J8499,HCPCS,outpatient,1,UN,75,45.00,,45,60,,36,percent of total billed charges,60% of total billed charges,36,48,,28.8,percent of total billed charges,48% of total billed charges,37.5,50,,30,percent of total billed charges,50% of total billed charges,37.5,50,,30,percent of total billed charges,50% of total billed charges,37.5,50,,30,percent of total billed charges,50% of total billed charges,37.5,50,,30,percent of total billed charges,50% of total billed charges,52.5,70,,42,percent of total billed charges,70% of total billed charges,36.36,48.48,,29.088,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,36.36,48.48,,29.088,percent of total billed charges,48.48% of total billed charges,52.5,70,,42,percent of total billed charges,70% of total billed charges,52.5,70,,42,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,36.36,48.48,,29.088,percent of total billed charges,48.48% of total billed charges,67.5,90,,54,percent of total billed charges,90% of total billed charges,36.36,90,
A&D OINTMENT 2 OZ,,,259,RC,A9150,HCPCS,outpatient,1,UN,13,7.80,,7.8,60,,6.24,percent of total billed charges,60% of total billed charges,6.24,48,,4.992,percent of total billed charges,48% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,9.1,70,,7.28,percent of total billed charges,70% of total billed charges,6.3,48.48,,5.04,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,6.3,48.48,,5.04,percent of total billed charges,48.48% of total billed charges,9.1,70,,7.28,percent of total billed charges,70% of total billed charges,9.1,70,,7.28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,6.3,48.48,,5.04,percent of total billed charges,48.48% of total billed charges,11.7,90,,9.36,percent of total billed charges,90% of total billed charges,6.3,90,
POLYTRIM(POLY-B/TRIMETH) OPTH,,,259,RC,J3490,HCPCS,outpatient,1,UN,54,32.40,,32.4,60,,25.92,percent of total billed charges,60% of total billed charges,25.92,48,,20.736,percent of total billed charges,48% of total billed charges,27,50,,21.6,percent of total billed charges,50% of total billed charges,27,50,,21.6,percent of total billed charges,50% of total billed charges,27,50,,21.6,percent of total billed charges,50% of total billed charges,27,50,,21.6,percent of total billed charges,50% of total billed charges,37.8,70,,30.24,percent of total billed charges,70% of total billed charges,26.18,48.48,,20.944,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,26.18,48.48,,20.944,percent of total billed charges,48.48% of total billed charges,37.8,70,,30.24,percent of total billed charges,70% of total billed charges,37.8,70,,30.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,26.18,48.48,,20.944,percent of total billed charges,48.48% of total billed charges,48.6,90,,38.88,percent of total billed charges,90% of total billed charges,26.18,90,
NOC^ ONDANSETRON ODT 4 MG,,,251,RC,J8597,HCPCS,outpatient,1,UN,93,55.80,,55.8,60,,44.64,percent of total billed charges,60% of total billed charges,44.64,48,,35.712,percent of total billed charges,48% of total billed charges,46.5,50,,37.2,percent of total billed charges,50% of total billed charges,46.5,50,,37.2,percent of total billed charges,50% of total billed charges,46.5,50,,37.2,percent of total billed charges,50% of total billed charges,46.5,50,,37.2,percent of total billed charges,50% of total billed charges,65.1,70,,52.08,percent of total billed charges,70% of total billed charges,45.09,48.48,,36.072,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,45.09,48.48,,36.072,percent of total billed charges,48.48% of total billed charges,65.1,70,,52.08,percent of total billed charges,70% of total billed charges,65.1,70,,52.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,45.09,48.48,,36.072,percent of total billed charges,48.48% of total billed charges,83.7,90,,66.96,percent of total billed charges,90% of total billed charges,45.09,90,
NOC^ ONDANSETRON SOL 4MG/5ML,,,259,RC,J3490,HCPCS,outpatient,1,UN,43,25.80,,25.8,60,,20.64,percent of total billed charges,60% of total billed charges,20.64,48,,16.512,percent of total billed charges,48% of total billed charges,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,30.1,70,,24.08,percent of total billed charges,70% of total billed charges,20.85,48.48,,16.68,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,20.85,48.48,,16.68,percent of total billed charges,48.48% of total billed charges,30.1,70,,24.08,percent of total billed charges,70% of total billed charges,30.1,70,,24.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,20.85,48.48,,16.68,percent of total billed charges,48.48% of total billed charges,38.7,90,,30.96,percent of total billed charges,90% of total billed charges,20.85,90,
NOC^ LANTISEPTIC OINT 14 OZ,,,259,RC,J3490,HCPCS,outpatient,1,UN,37,22.20,,22.2,60,,17.76,percent of total billed charges,60% of total billed charges,17.76,48,,14.208,percent of total billed charges,48% of total billed charges,18.5,50,,14.8,percent of total billed charges,50% of total billed charges,18.5,50,,14.8,percent of total billed charges,50% of total billed charges,18.5,50,,14.8,percent of total billed charges,50% of total billed charges,18.5,50,,14.8,percent of total billed charges,50% of total billed charges,25.9,70,,20.72,percent of total billed charges,70% of total billed charges,17.94,48.48,,14.352,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,17.94,48.48,,14.352,percent of total billed charges,48.48% of total billed charges,25.9,70,,20.72,percent of total billed charges,70% of total billed charges,25.9,70,,20.72,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,17.94,48.48,,14.352,percent of total billed charges,48.48% of total billed charges,33.3,90,,26.64,percent of total billed charges,90% of total billed charges,17.94,90,
NOC^ OFLOXACIN OPTH .3% 5 ML,,,250,RC,J3490,HCPCS,outpatient,1,UN,55,33.00,,33,60,,26.4,percent of total billed charges,60% of total billed charges,26.4,48,,21.12,percent of total billed charges,48% of total billed charges,27.5,50,,22,percent of total billed charges,50% of total billed charges,27.5,50,,22,percent of total billed charges,50% of total billed charges,27.5,50,,22,percent of total billed charges,50% of total billed charges,27.5,50,,22,percent of total billed charges,50% of total billed charges,38.5,70,,30.8,percent of total billed charges,70% of total billed charges,26.66,48.48,,21.328,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,26.66,48.48,,21.328,percent of total billed charges,48.48% of total billed charges,38.5,70,,30.8,percent of total billed charges,70% of total billed charges,38.5,70,,30.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,26.66,48.48,,21.328,percent of total billed charges,48.48% of total billed charges,49.5,90,,39.6,percent of total billed charges,90% of total billed charges,26.66,90,
NOC^ OFLOXACIN OTIC SOL 0.3%,,,250,RC,J3490,HCPCS,outpatient,1,UN,74,44.40,,44.4,60,,35.52,percent of total billed charges,60% of total billed charges,35.52,48,,28.416,percent of total billed charges,48% of total billed charges,37,50,,29.6,percent of total billed charges,50% of total billed charges,37,50,,29.6,percent of total billed charges,50% of total billed charges,37,50,,29.6,percent of total billed charges,50% of total billed charges,37,50,,29.6,percent of total billed charges,50% of total billed charges,51.8,70,,41.44,percent of total billed charges,70% of total billed charges,35.88,48.48,,28.704,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,35.88,48.48,,28.704,percent of total billed charges,48.48% of total billed charges,51.8,70,,41.44,percent of total billed charges,70% of total billed charges,51.8,70,,41.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,35.88,48.48,,28.704,percent of total billed charges,48.48% of total billed charges,66.6,90,,53.28,percent of total billed charges,90% of total billed charges,35.88,90,
NOC^ CITALOPRAM TAB 40 MG,,,259,RC,J3490,HCPCS,outpatient,1,UN,11,6.60,,6.6,60,,5.28,percent of total billed charges,60% of total billed charges,5.28,48,,4.224,percent of total billed charges,48% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,9.9,90,,7.92,percent of total billed charges,90% of total billed charges,5.33,90,
NOC^ OMEPRAZOLE CAP 40MG,,,259,RC,J3490,HCPCS,outpatient,1,UN,30,18.00,,18,60,,14.4,percent of total billed charges,60% of total billed charges,14.4,48,,11.52,percent of total billed charges,48% of total billed charges,15,50,,12,percent of total billed charges,50% of total billed charges,15,50,,12,percent of total billed charges,50% of total billed charges,15,50,,12,percent of total billed charges,50% of total billed charges,15,50,,12,percent of total billed charges,50% of total billed charges,21,70,,16.8,percent of total billed charges,70% of total billed charges,14.54,48.48,,11.632,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,14.54,48.48,,11.632,percent of total billed charges,48.48% of total billed charges,21,70,,16.8,percent of total billed charges,70% of total billed charges,21,70,,16.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,14.54,48.48,,11.632,percent of total billed charges,48.48% of total billed charges,27,90,,21.6,percent of total billed charges,90% of total billed charges,14.54,90,
NOC^ NEBIVOLOL HCL TAB 5 MG,,,252,RC,J8499,HCPCS,outpatient,1,UN,11,6.60,,6.6,60,,5.28,percent of total billed charges,60% of total billed charges,5.28,48,,4.224,percent of total billed charges,48% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,9.9,90,,7.92,percent of total billed charges,90% of total billed charges,5.33,90,
NOC^ NEBIVOLOL HCL TAB 10 MG,,,252,RC,J8499,HCPCS,outpatient,1,UN,11,6.60,,6.6,60,,5.28,percent of total billed charges,60% of total billed charges,5.28,48,,4.224,percent of total billed charges,48% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,9.9,90,,7.92,percent of total billed charges,90% of total billed charges,5.33,90,
NOC^ LEVETIRACETAM O/SOL 100MG,,,259,RC,J3490,HCPCS,outpatient,1,UN,38,22.80,,22.8,60,,18.24,percent of total billed charges,60% of total billed charges,18.24,48,,14.592,percent of total billed charges,48% of total billed charges,19,50,,15.2,percent of total billed charges,50% of total billed charges,19,50,,15.2,percent of total billed charges,50% of total billed charges,19,50,,15.2,percent of total billed charges,50% of total billed charges,19,50,,15.2,percent of total billed charges,50% of total billed charges,26.6,70,,21.28,percent of total billed charges,70% of total billed charges,18.42,48.48,,14.736,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,18.42,48.48,,14.736,percent of total billed charges,48.48% of total billed charges,26.6,70,,21.28,percent of total billed charges,70% of total billed charges,26.6,70,,21.28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,18.42,48.48,,14.736,percent of total billed charges,48.48% of total billed charges,34.2,90,,27.36,percent of total billed charges,90% of total billed charges,18.42,90,
MAG SULF 2G/50ML PREMIX,,,250,RC,J3475,HCPCS,outpatient,1,UN,71,42.60,,42.6,60,,34.08,percent of total billed charges,60% of total billed charges,34.08,48,,27.264,percent of total billed charges,48% of total billed charges,0.46,100,,,fee schedule,100% of bcbs custom fee schedule,0.46,100,,,fee schedule,100% of bcbs custom fee schedule,0.51,111,,,fee schedule,111% of bcbs custom fee schedule,35.5,50,,28.4,percent of total billed charges,50% of total billed charges,49.7,70,,39.76,percent of total billed charges,70% of total billed charges,34.42,48.48,,27.536,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,34.42,48.48,,27.536,percent of total billed charges,48.48% of total billed charges,49.7,70,,39.76,percent of total billed charges,70% of total billed charges,49.7,70,,39.76,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,34.42,48.48,,27.536,percent of total billed charges,48.48% of total billed charges,63.9,90,,51.12,percent of total billed charges,90% of total billed charges,34.42,90,
NOC^ AMLODIPINE/VALSARTAN 5/16,,,259,RC,J8499,HCPCS,outpatient,1,UN,43,25.80,,25.8,60,,20.64,percent of total billed charges,60% of total billed charges,20.64,48,,16.512,percent of total billed charges,48% of total billed charges,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,30.1,70,,24.08,percent of total billed charges,70% of total billed charges,20.85,48.48,,16.68,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,20.85,48.48,,16.68,percent of total billed charges,48.48% of total billed charges,30.1,70,,24.08,percent of total billed charges,70% of total billed charges,30.1,70,,24.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,20.85,48.48,,16.68,percent of total billed charges,48.48% of total billed charges,38.7,90,,30.96,percent of total billed charges,90% of total billed charges,20.85,90,
NOC^ PARICALCITOL CAP 1 MCG,,,252,RC,J8499,HCPCS,outpatient,1,UN,50,30.00,,30,60,,24,percent of total billed charges,60% of total billed charges,24,48,,19.2,percent of total billed charges,48% of total billed charges,25,50,,20,percent of total billed charges,50% of total billed charges,25,50,,20,percent of total billed charges,50% of total billed charges,25,50,,20,percent of total billed charges,50% of total billed charges,25,50,,20,percent of total billed charges,50% of total billed charges,35,70,,28,percent of total billed charges,70% of total billed charges,24.24,48.48,,19.392,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,24.24,48.48,,19.392,percent of total billed charges,48.48% of total billed charges,35,70,,28,percent of total billed charges,70% of total billed charges,35,70,,28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,24.24,48.48,,19.392,percent of total billed charges,48.48% of total billed charges,45,90,,36,percent of total billed charges,90% of total billed charges,24.24,90,
NOC^ DIPHENHYDRAMINE CRM 1 OZ,,,259,RC,J3490,HCPCS,outpatient,1,UN,16,9.60,,9.6,60,,7.68,percent of total billed charges,60% of total billed charges,7.68,48,,6.144,percent of total billed charges,48% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,11.2,70,,8.96,percent of total billed charges,70% of total billed charges,7.76,48.48,,6.208,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,7.76,48.48,,6.208,percent of total billed charges,48.48% of total billed charges,11.2,70,,8.96,percent of total billed charges,70% of total billed charges,11.2,70,,8.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,7.76,48.48,,6.208,percent of total billed charges,48.48% of total billed charges,14.4,90,,11.52,percent of total billed charges,90% of total billed charges,7.76,90,
NOC^ OLOPATADINE OPTH SOL 0.2%,,,252,RC,J3490,HCPCS,outpatient,1,UN,359,215.40,,215.4,60,,172.32,percent of total billed charges,60% of total billed charges,172.32,48,,137.856,percent of total billed charges,48% of total billed charges,179.5,50,,143.6,percent of total billed charges,50% of total billed charges,179.5,50,,143.6,percent of total billed charges,50% of total billed charges,179.5,50,,143.6,percent of total billed charges,50% of total billed charges,179.5,50,,143.6,percent of total billed charges,50% of total billed charges,251.3,70,,201.04,percent of total billed charges,70% of total billed charges,174.04,48.48,,139.232,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,174.04,48.48,,139.232,percent of total billed charges,48.48% of total billed charges,251.3,70,,201.04,percent of total billed charges,70% of total billed charges,251.3,70,,201.04,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,174.04,48.48,,139.232,percent of total billed charges,48.48% of total billed charges,323.1,90,,258.48,percent of total billed charges,90% of total billed charges,48.48,323.1,
NOC^ DULOXETINE CAP [20 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,33,19.80,,19.8,60,,15.84,percent of total billed charges,60% of total billed charges,15.84,48,,12.672,percent of total billed charges,48% of total billed charges,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,23.1,70,,18.48,percent of total billed charges,70% of total billed charges,16,48.48,,12.8,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,16,48.48,,12.8,percent of total billed charges,48.48% of total billed charges,23.1,70,,18.48,percent of total billed charges,70% of total billed charges,23.1,70,,18.48,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,16,48.48,,12.8,percent of total billed charges,48.48% of total billed charges,29.7,90,,23.76,percent of total billed charges,90% of total billed charges,16,90,
FAMOTIDINE INJ 40MG,,,250,RC,S0028,HCPCS,outpatient,2,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,1.02,100,,,fee schedule,100% of bcbs custom fee schedule,1.02,100,,,fee schedule,100% of bcbs custom fee schedule,1.13,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
NOC^ CITALOPRAM TAB 10 MG,,,259,RC,J3490,HCPCS,outpatient,1,UN,11,6.60,,6.6,60,,5.28,percent of total billed charges,60% of total billed charges,5.28,48,,4.224,percent of total billed charges,48% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,9.9,90,,7.92,percent of total billed charges,90% of total billed charges,5.33,90,
KETOROLAC INJ 15 MG/ML,43601515,CDM,636,RC,J1885,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,0.74,100,,,fee schedule,100% of bcbs custom fee schedule,0.74,100,,,fee schedule,100% of bcbs custom fee schedule,0.82,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
NOC^ CYCLOPENTOLATE 1% OPTH,,,259,RC,J3490,HCPCS,outpatient,1,UN,60,36.00,,36,60,,28.8,percent of total billed charges,60% of total billed charges,28.8,48,,23.04,percent of total billed charges,48% of total billed charges,30,50,,24,percent of total billed charges,50% of total billed charges,30,50,,24,percent of total billed charges,50% of total billed charges,30,50,,24,percent of total billed charges,50% of total billed charges,30,50,,24,percent of total billed charges,50% of total billed charges,42,70,,33.6,percent of total billed charges,70% of total billed charges,29.09,48.48,,23.272,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,29.09,48.48,,23.272,percent of total billed charges,48.48% of total billed charges,42,70,,33.6,percent of total billed charges,70% of total billed charges,42,70,,33.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,29.09,48.48,,23.272,percent of total billed charges,48.48% of total billed charges,54,90,,43.2,percent of total billed charges,90% of total billed charges,29.09,90,
NOC^ DABIGATRAN CAP 75 MG,,,259,RC,J8499,HCPCS,outpatient,1,UN,17,10.20,,10.2,60,,8.16,percent of total billed charges,60% of total billed charges,8.16,48,,6.528,percent of total billed charges,48% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,11.9,70,,9.52,percent of total billed charges,70% of total billed charges,8.24,48.48,,6.592,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,8.24,48.48,,6.592,percent of total billed charges,48.48% of total billed charges,11.9,70,,9.52,percent of total billed charges,70% of total billed charges,11.9,70,,9.52,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,8.24,48.48,,6.592,percent of total billed charges,48.48% of total billed charges,15.3,90,,12.24,percent of total billed charges,90% of total billed charges,8.24,90,
NOC^ VASOPRESSIN 20 UNITS/ML,,,250,RC,J3490,HCPCS,outpatient,1,UN,1020,612.00,,612,60,,489.6,percent of total billed charges,60% of total billed charges,489.6,48,,391.68,percent of total billed charges,48% of total billed charges,510,50,,408,percent of total billed charges,50% of total billed charges,510,50,,408,percent of total billed charges,50% of total billed charges,510,50,,408,percent of total billed charges,50% of total billed charges,510,50,,408,percent of total billed charges,50% of total billed charges,714,70,,571.2,percent of total billed charges,70% of total billed charges,494.5,48.48,,395.6,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,494.5,48.48,,395.6,percent of total billed charges,48.48% of total billed charges,714,70,,571.2,percent of total billed charges,70% of total billed charges,714,70,,571.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,494.5,48.48,,395.6,percent of total billed charges,48.48% of total billed charges,918,90,,734.4,percent of total billed charges,90% of total billed charges,48.48,918,
MIDAZOLAM INJ 2MG/2ML,,,250,RC,J2250,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,0.14,100,,,fee schedule,100% of bcbs custom fee schedule,0.14,100,,,fee schedule,100% of bcbs custom fee schedule,0.16,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
NOC^ TOBRAMYCIN OPTH DROP 0.3%,,,259,RC,J3490,HCPCS,outpatient,1,UN,59,35.40,,35.4,60,,28.32,percent of total billed charges,60% of total billed charges,28.32,48,,22.656,percent of total billed charges,48% of total billed charges,29.5,50,,23.6,percent of total billed charges,50% of total billed charges,29.5,50,,23.6,percent of total billed charges,50% of total billed charges,29.5,50,,23.6,percent of total billed charges,50% of total billed charges,29.5,50,,23.6,percent of total billed charges,50% of total billed charges,41.3,70,,33.04,percent of total billed charges,70% of total billed charges,28.6,48.48,,22.88,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,28.6,48.48,,22.88,percent of total billed charges,48.48% of total billed charges,41.3,70,,33.04,percent of total billed charges,70% of total billed charges,41.3,70,,33.04,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,28.6,48.48,,22.88,percent of total billed charges,48.48% of total billed charges,53.1,90,,42.48,percent of total billed charges,90% of total billed charges,28.6,90,
NOC^ LEVOFLOXACIN TAB 750MG,,,259,RC,J8499,HCPCS,outpatient,1,UN,99,59.40,,59.4,60,,47.52,percent of total billed charges,60% of total billed charges,47.52,48,,38.016,percent of total billed charges,48% of total billed charges,49.5,50,,39.6,percent of total billed charges,50% of total billed charges,49.5,50,,39.6,percent of total billed charges,50% of total billed charges,49.5,50,,39.6,percent of total billed charges,50% of total billed charges,49.5,50,,39.6,percent of total billed charges,50% of total billed charges,69.3,70,,55.44,percent of total billed charges,70% of total billed charges,48,48.48,,38.4,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,48,48.48,,38.4,percent of total billed charges,48.48% of total billed charges,69.3,70,,55.44,percent of total billed charges,70% of total billed charges,69.3,70,,55.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,48,48.48,,38.4,percent of total billed charges,48.48% of total billed charges,89.1,90,,71.28,percent of total billed charges,90% of total billed charges,48,90,
ZOLEDRONIC ACID IVPB 4MG/100 ML,,,636,RC,J3489,HCPCS,outpatient,1,UN,864,518.40,,518.4,60,,414.72,percent of total billed charges,60% of total billed charges,414.72,48,,331.776,percent of total billed charges,48% of total billed charges,10.68,100,,,fee schedule,100% of bcbs custom fee schedule,10.68,100,,,fee schedule,100% of bcbs custom fee schedule,11.85,111,,,fee schedule,111% of bcbs custom fee schedule,432,50,,345.6,percent of total billed charges,50% of total billed charges,604.8,70,,483.84,percent of total billed charges,70% of total billed charges,418.87,48.48,,335.096,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,418.87,48.48,,335.096,percent of total billed charges,48.48% of total billed charges,604.8,70,,483.84,percent of total billed charges,70% of total billed charges,604.8,70,,483.84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,418.87,48.48,,335.096,percent of total billed charges,48.48% of total billed charges,777.6,90,,622.08,percent of total billed charges,90% of total billed charges,48.48,777.6,
NOC^ FEBUXOSTAT TAB 40 MG,,,259,RC,J8499,HCPCS,outpatient,1,UN,41,24.60,,24.6,60,,19.68,percent of total billed charges,60% of total billed charges,19.68,48,,15.744,percent of total billed charges,48% of total billed charges,20.5,50,,16.4,percent of total billed charges,50% of total billed charges,20.5,50,,16.4,percent of total billed charges,50% of total billed charges,20.5,50,,16.4,percent of total billed charges,50% of total billed charges,20.5,50,,16.4,percent of total billed charges,50% of total billed charges,28.7,70,,22.96,percent of total billed charges,70% of total billed charges,19.88,48.48,,15.904,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,19.88,48.48,,15.904,percent of total billed charges,48.48% of total billed charges,28.7,70,,22.96,percent of total billed charges,70% of total billed charges,28.7,70,,22.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,19.88,48.48,,15.904,percent of total billed charges,48.48% of total billed charges,36.9,90,,29.52,percent of total billed charges,90% of total billed charges,19.88,90,
BUDESONIDE/FORMOTEROL INH 80/4.5,,,250,RC,J3535,HCPCS,outpatient,1,UN,1054,632.40,,632.4,60,,505.92,percent of total billed charges,60% of total billed charges,505.92,48,,404.736,percent of total billed charges,48% of total billed charges,527,50,,421.6,percent of total billed charges,50% of total billed charges,527,50,,421.6,percent of total billed charges,50% of total billed charges,527,50,,421.6,percent of total billed charges,50% of total billed charges,527,50,,421.6,percent of total billed charges,50% of total billed charges,737.8,70,,590.24,percent of total billed charges,70% of total billed charges,510.98,48.48,,408.784,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,510.98,48.48,,408.784,percent of total billed charges,48.48% of total billed charges,737.8,70,,590.24,percent of total billed charges,70% of total billed charges,737.8,70,,590.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,510.98,48.48,,408.784,percent of total billed charges,48.48% of total billed charges,948.6,90,,758.88,percent of total billed charges,90% of total billed charges,48.48,948.6,
INS- LEVEMIR INJ (100U/ML,,,636,RC,J1815,HCPCS,outpatient,1,UN,74,44.40,,44.4,60,,35.52,percent of total billed charges,60% of total billed charges,35.52,48,,28.416,percent of total billed charges,48% of total billed charges,0.96,100,,,fee schedule,100% of bcbs custom fee schedule,0.96,100,,,fee schedule,100% of bcbs custom fee schedule,1.07,111,,,fee schedule,111% of bcbs custom fee schedule,37,50,,29.6,percent of total billed charges,50% of total billed charges,51.8,70,,41.44,percent of total billed charges,70% of total billed charges,35.88,48.48,,28.704,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,35.88,48.48,,28.704,percent of total billed charges,48.48% of total billed charges,51.8,70,,41.44,percent of total billed charges,70% of total billed charges,51.8,70,,41.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,35.88,48.48,,28.704,percent of total billed charges,48.48% of total billed charges,66.6,90,,53.28,percent of total billed charges,90% of total billed charges,35.88,90,
NOC^ RIVAROXABAN TAB 10 MG,,,252,RC,J8499,HCPCS,outpatient,1,UN,43,25.80,,25.8,60,,20.64,percent of total billed charges,60% of total billed charges,20.64,48,,16.512,percent of total billed charges,48% of total billed charges,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,30.1,70,,24.08,percent of total billed charges,70% of total billed charges,20.85,48.48,,16.68,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,20.85,48.48,,16.68,percent of total billed charges,48.48% of total billed charges,30.1,70,,24.08,percent of total billed charges,70% of total billed charges,30.1,70,,24.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,20.85,48.48,,16.68,percent of total billed charges,48.48% of total billed charges,38.7,90,,30.96,percent of total billed charges,90% of total billed charges,20.85,90,
NOC^ DIVALPROEX ER TAB 250 MG,,,259,RC,J8499,HCPCS,outpatient,1,UN,11,6.60,,6.6,60,,5.28,percent of total billed charges,60% of total billed charges,5.28,48,,4.224,percent of total billed charges,48% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,9.9,90,,7.92,percent of total billed charges,90% of total billed charges,5.33,90,
NOC^ ELIQUIS TAB [2.5 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,21,12.60,,12.6,60,,10.08,percent of total billed charges,60% of total billed charges,10.08,48,,8.064,percent of total billed charges,48% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,14.7,70,,11.76,percent of total billed charges,70% of total billed charges,10.18,48.48,,8.144,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,10.18,48.48,,8.144,percent of total billed charges,48.48% of total billed charges,14.7,70,,11.76,percent of total billed charges,70% of total billed charges,14.7,70,,11.76,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,10.18,48.48,,8.144,percent of total billed charges,48.48% of total billed charges,18.9,90,,15.12,percent of total billed charges,90% of total billed charges,10.18,90,
ERTAPENEM 1G/20 ML INJ,,,636,RC,J1335,HCPCS,outpatient,2,UN,618,370.80,,370.8,60,,296.64,percent of total billed charges,60% of total billed charges,296.64,48,,237.312,percent of total billed charges,48% of total billed charges,36.08,100,,,fee schedule,100% of bcbs custom fee schedule,36.08,100,,,fee schedule,100% of bcbs custom fee schedule,40.05,111,,,fee schedule,111% of bcbs custom fee schedule,309,50,,247.2,percent of total billed charges,50% of total billed charges,432.6,70,,346.08,percent of total billed charges,70% of total billed charges,299.61,48.48,,239.688,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,299.61,48.48,,239.688,percent of total billed charges,48.48% of total billed charges,432.6,70,,346.08,percent of total billed charges,70% of total billed charges,432.6,70,,346.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,299.61,48.48,,239.688,percent of total billed charges,48.48% of total billed charges,556.2,90,,444.96,percent of total billed charges,90% of total billed charges,48.48,556.2,
ACETYLCYSTEINE SOL 20%,43104056,CDM,250,RC,J7608,HCPCS,outpatient,1,UN,60,36.00,,36,60,,28.8,percent of total billed charges,60% of total billed charges,28.8,48,,23.04,percent of total billed charges,48% of total billed charges,6.51,100,,,fee schedule,100% of bcbs custom fee schedule,6.51,100,,,fee schedule,100% of bcbs custom fee schedule,7.23,111,,,fee schedule,111% of bcbs custom fee schedule,30,50,,24,percent of total billed charges,50% of total billed charges,42,70,,33.6,percent of total billed charges,70% of total billed charges,29.09,48.48,,23.272,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,29.09,48.48,,23.272,percent of total billed charges,48.48% of total billed charges,42,70,,33.6,percent of total billed charges,70% of total billed charges,42,70,,33.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,29.09,48.48,,23.272,percent of total billed charges,48.48% of total billed charges,54,90,,43.2,percent of total billed charges,90% of total billed charges,29.09,90,
NEULASTA 6MG/0.6ML INJ,,,636,RC,J2506,HCPCS,outpatient,12,UN,14955,8973.00,,8973,60,,7178.4,percent of total billed charges,60% of total billed charges,7178.4,48,,5742.72,percent of total billed charges,48% of total billed charges,7477.5,50,,5982,percent of total billed charges,50% of total billed charges,7477.5,50,,5982,percent of total billed charges,50% of total billed charges,7477.5,50,,5982,percent of total billed charges,50% of total billed charges,7477.5,50,,5982,percent of total billed charges,50% of total billed charges,10468.5,70,,8374.8,percent of total billed charges,70% of total billed charges,7250.18,48.48,,5800.144,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,7250.18,48.48,,5800.144,percent of total billed charges,48.48% of total billed charges,10468.5,70,,8374.8,percent of total billed charges,70% of total billed charges,10468.5,70,,8374.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,7250.18,48.48,,5800.144,percent of total billed charges,48.48% of total billed charges,13459.5,90,,10767.6,percent of total billed charges,90% of total billed charges,48.48,13459.5,
FERUMOXYTOL INJ 510 MG,,,636,RC,Q0138,HCPCS,outpatient,1,UN,5730,3438.00,,3438,60,,2750.4,percent of total billed charges,60% of total billed charges,2750.4,48,,2200.32,percent of total billed charges,48% of total billed charges,1.08,100,,,fee schedule,100% of bcbs custom fee schedule,1.08,100,,,fee schedule,100% of bcbs custom fee schedule,1.2,111,,,fee schedule,111% of bcbs custom fee schedule,2865,50,,2292,percent of total billed charges,50% of total billed charges,4011,70,,3208.8,percent of total billed charges,70% of total billed charges,2777.9,48.48,,2222.32,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,2777.9,48.48,,2222.32,percent of total billed charges,48.48% of total billed charges,4011,70,,3208.8,percent of total billed charges,70% of total billed charges,4011,70,,3208.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,2777.9,48.48,,2222.32,percent of total billed charges,48.48% of total billed charges,5157,90,,4125.6,percent of total billed charges,90% of total billed charges,48.48,5157,
NOC^ BRIMONIDINE 0.2% DRP,,,259,RC,J3490,HCPCS,outpatient,1,UN,131,78.60,,78.6,60,,62.88,percent of total billed charges,60% of total billed charges,62.88,48,,50.304,percent of total billed charges,48% of total billed charges,65.5,50,,52.4,percent of total billed charges,50% of total billed charges,65.5,50,,52.4,percent of total billed charges,50% of total billed charges,65.5,50,,52.4,percent of total billed charges,50% of total billed charges,65.5,50,,52.4,percent of total billed charges,50% of total billed charges,91.7,70,,73.36,percent of total billed charges,70% of total billed charges,63.51,48.48,,50.808,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,63.51,48.48,,50.808,percent of total billed charges,48.48% of total billed charges,91.7,70,,73.36,percent of total billed charges,70% of total billed charges,91.7,70,,73.36,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,63.51,48.48,,50.808,percent of total billed charges,48.48% of total billed charges,117.9,90,,94.32,percent of total billed charges,90% of total billed charges,48.48,117.9,
NOC^ PROTEINEX LIQ 16 OZ,,,250,RC,J3490,HCPCS,outpatient,1,UN,88,52.80,,52.8,60,,42.24,percent of total billed charges,60% of total billed charges,42.24,48,,33.792,percent of total billed charges,48% of total billed charges,44,50,,35.2,percent of total billed charges,50% of total billed charges,44,50,,35.2,percent of total billed charges,50% of total billed charges,44,50,,35.2,percent of total billed charges,50% of total billed charges,44,50,,35.2,percent of total billed charges,50% of total billed charges,61.6,70,,49.28,percent of total billed charges,70% of total billed charges,42.66,48.48,,34.128,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,42.66,48.48,,34.128,percent of total billed charges,48.48% of total billed charges,61.6,70,,49.28,percent of total billed charges,70% of total billed charges,61.6,70,,49.28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,42.66,48.48,,34.128,percent of total billed charges,48.48% of total billed charges,79.2,90,,63.36,percent of total billed charges,90% of total billed charges,42.66,90,
NOC^ MEMANTINE XR 28 MG,,,259,RC,J8499,HCPCS,outpatient,1,UN,62,37.20,,37.2,60,,29.76,percent of total billed charges,60% of total billed charges,29.76,48,,23.808,percent of total billed charges,48% of total billed charges,31,50,,24.8,percent of total billed charges,50% of total billed charges,31,50,,24.8,percent of total billed charges,50% of total billed charges,31,50,,24.8,percent of total billed charges,50% of total billed charges,31,50,,24.8,percent of total billed charges,50% of total billed charges,43.4,70,,34.72,percent of total billed charges,70% of total billed charges,30.06,48.48,,24.048,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,30.06,48.48,,24.048,percent of total billed charges,48.48% of total billed charges,43.4,70,,34.72,percent of total billed charges,70% of total billed charges,43.4,70,,34.72,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,30.06,48.48,,24.048,percent of total billed charges,48.48% of total billed charges,55.8,90,,44.64,percent of total billed charges,90% of total billed charges,30.06,90,
"SLIPPER, TERRY SOCK (NON-SKID SLIPPERS)",,,279,RC,,,outpatient,,,12.5,7.50,,7.5,60,,6,percent of total billed charges,60% of total billed charges,6,48,,4.8,percent of total billed charges,48% of total billed charges,6.25,50,,5,percent of total billed charges,50% of total billed charges,6.25,50,,5,percent of total billed charges,50% of total billed charges,6.25,50,,5,percent of total billed charges,50% of total billed charges,6.25,50,,5,percent of total billed charges,50% of total billed charges,8.75,70,,7,percent of total billed charges,70% of total billed charges,6.06,48.48,,4.848,percent of total billed charges,48.48% of total billed charges,6.06,48.48,,4.848,percent of total billed charges,48.48% of total billed charges,6.06,48.48,,4.848,percent of total billed charges,48.48% of total billed charges,8.75,70,,7,percent of total billed charges,70% of total billed charges,8.75,70,,7,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,6.06,48.48,,4.848,percent of total billed charges,48.48% of total billed charges,11.25,90,,9,percent of total billed charges,90% of total billed charges,6.06,90,
CLINIMIX E 4.25/5 PREMIX,,,636,RC,B4189,HCPCS,outpatient,1,UN,152,91.20,,91.2,60,,72.96,percent of total billed charges,60% of total billed charges,72.96,48,,58.368,percent of total billed charges,48% of total billed charges,135.04,100,,,fee schedule,100% of bcbs custom fee schedule,135.04,100,,,fee schedule,100% of bcbs custom fee schedule,149.89,111,,,fee schedule,111% of bcbs custom fee schedule,76,50,,60.8,percent of total billed charges,50% of total billed charges,106.4,70,,85.12,percent of total billed charges,70% of total billed charges,73.69,48.48,,58.952,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,73.69,48.48,,58.952,percent of total billed charges,48.48% of total billed charges,106.4,70,,85.12,percent of total billed charges,70% of total billed charges,106.4,70,,85.12,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,73.69,48.48,,58.952,percent of total billed charges,48.48% of total billed charges,136.8,90,,109.44,percent of total billed charges,90% of total billed charges,48.48,136.8,
NOC^ HYDROCORTISONE SPRAY 1%,,,250,RC,J3490,HCPCS,outpatient,1,UN,27,16.20,,16.2,60,,12.96,percent of total billed charges,60% of total billed charges,12.96,48,,10.368,percent of total billed charges,48% of total billed charges,13.5,50,,10.8,percent of total billed charges,50% of total billed charges,13.5,50,,10.8,percent of total billed charges,50% of total billed charges,13.5,50,,10.8,percent of total billed charges,50% of total billed charges,13.5,50,,10.8,percent of total billed charges,50% of total billed charges,18.9,70,,15.12,percent of total billed charges,70% of total billed charges,13.09,48.48,,10.472,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,13.09,48.48,,10.472,percent of total billed charges,48.48% of total billed charges,18.9,70,,15.12,percent of total billed charges,70% of total billed charges,18.9,70,,15.12,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,13.09,48.48,,10.472,percent of total billed charges,48.48% of total billed charges,24.3,90,,19.44,percent of total billed charges,90% of total billed charges,13.09,90,
FAT EMULSIONS 20% IV,,,636,RC,B4185,HCPCS,outpatient,1,UN,212,127.20,,127.2,60,,101.76,percent of total billed charges,60% of total billed charges,101.76,48,,81.408,percent of total billed charges,48% of total billed charges,8.53,100,,,fee schedule,100% of bcbs custom fee schedule,8.53,100,,,fee schedule,100% of bcbs custom fee schedule,9.47,111,,,fee schedule,111% of bcbs custom fee schedule,106,50,,84.8,percent of total billed charges,50% of total billed charges,148.4,70,,118.72,percent of total billed charges,70% of total billed charges,102.78,48.48,,82.224,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,102.78,48.48,,82.224,percent of total billed charges,48.48% of total billed charges,148.4,70,,118.72,percent of total billed charges,70% of total billed charges,148.4,70,,118.72,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,102.78,48.48,,82.224,percent of total billed charges,48.48% of total billed charges,190.8,90,,152.64,percent of total billed charges,90% of total billed charges,48.48,190.8,
CLINIMIX 4.25/10 PREMIX,,,636,RC,B4176,HCPCS,outpatient,1,UN,266,159.60,,159.6,60,,127.68,percent of total billed charges,60% of total billed charges,127.68,48,,102.144,percent of total billed charges,48% of total billed charges,133,50,,106.4,percent of total billed charges,50% of total billed charges,133,50,,106.4,percent of total billed charges,50% of total billed charges,133,50,,106.4,percent of total billed charges,50% of total billed charges,133,50,,106.4,percent of total billed charges,50% of total billed charges,186.2,70,,148.96,percent of total billed charges,70% of total billed charges,128.96,48.48,,103.168,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,128.96,48.48,,103.168,percent of total billed charges,48.48% of total billed charges,186.2,70,,148.96,percent of total billed charges,70% of total billed charges,186.2,70,,148.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,128.96,48.48,,103.168,percent of total billed charges,48.48% of total billed charges,239.4,90,,191.52,percent of total billed charges,90% of total billed charges,48.48,239.4,
NOC^ CANDESARTAN 4 MG,,,259,RC,J8499,HCPCS,outpatient,1,UN,13,7.80,,7.8,60,,6.24,percent of total billed charges,60% of total billed charges,6.24,48,,4.992,percent of total billed charges,48% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,9.1,70,,7.28,percent of total billed charges,70% of total billed charges,6.3,48.48,,5.04,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,6.3,48.48,,5.04,percent of total billed charges,48.48% of total billed charges,9.1,70,,7.28,percent of total billed charges,70% of total billed charges,9.1,70,,7.28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,6.3,48.48,,5.04,percent of total billed charges,48.48% of total billed charges,11.7,90,,9.36,percent of total billed charges,90% of total billed charges,6.3,90,
LEVOFLOXACIN 250MG IV PMX,,,636,RC,J1956,HCPCS,outpatient,1,UN,35,21.00,,21,60,,16.8,percent of total billed charges,60% of total billed charges,16.8,48,,13.44,percent of total billed charges,48% of total billed charges,0.44,100,,,fee schedule,100% of bcbs custom fee schedule,0.44,100,,,fee schedule,100% of bcbs custom fee schedule,0.49,111,,,fee schedule,111% of bcbs custom fee schedule,17.5,50,,14,percent of total billed charges,50% of total billed charges,24.5,70,,19.6,percent of total billed charges,70% of total billed charges,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,24.5,70,,19.6,percent of total billed charges,70% of total billed charges,24.5,70,,19.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,31.5,90,,25.2,percent of total billed charges,90% of total billed charges,16.97,90,
MEROPENEM INJ 500 MG,,,636,RC,J2185,HCPCS,outpatient,1,UN,70,42.00,,42,60,,33.6,percent of total billed charges,60% of total billed charges,33.6,48,,26.88,percent of total billed charges,48% of total billed charges,0.95,100,,,fee schedule,100% of bcbs custom fee schedule,0.95,100,,,fee schedule,100% of bcbs custom fee schedule,1.05,111,,,fee schedule,111% of bcbs custom fee schedule,35,50,,28,percent of total billed charges,50% of total billed charges,49,70,,39.2,percent of total billed charges,70% of total billed charges,33.94,48.48,,27.152,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,33.94,48.48,,27.152,percent of total billed charges,48.48% of total billed charges,49,70,,39.2,percent of total billed charges,70% of total billed charges,49,70,,39.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,33.94,48.48,,27.152,percent of total billed charges,48.48% of total billed charges,63,90,,50.4,percent of total billed charges,90% of total billed charges,33.94,90,
NOC^ SOD BICARB 4.2% INJ,,,636,RC,J3490,HCPCS,outpatient,1,UN,55,33.00,,33,60,,26.4,percent of total billed charges,60% of total billed charges,26.4,48,,21.12,percent of total billed charges,48% of total billed charges,27.5,50,,22,percent of total billed charges,50% of total billed charges,27.5,50,,22,percent of total billed charges,50% of total billed charges,27.5,50,,22,percent of total billed charges,50% of total billed charges,27.5,50,,22,percent of total billed charges,50% of total billed charges,38.5,70,,30.8,percent of total billed charges,70% of total billed charges,26.66,48.48,,21.328,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,26.66,48.48,,21.328,percent of total billed charges,48.48% of total billed charges,38.5,70,,30.8,percent of total billed charges,70% of total billed charges,38.5,70,,30.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,26.66,48.48,,21.328,percent of total billed charges,48.48% of total billed charges,49.5,90,,39.6,percent of total billed charges,90% of total billed charges,26.66,90,
CLINIMIX PER 500 ML,,,250,RC,B4164,HCPCS,outpatient,1,UN,64,38.40,,38.4,60,,30.72,percent of total billed charges,60% of total billed charges,30.72,48,,24.576,percent of total billed charges,48% of total billed charges,32,50,,25.6,percent of total billed charges,50% of total billed charges,32,50,,25.6,percent of total billed charges,50% of total billed charges,32,50,,25.6,percent of total billed charges,50% of total billed charges,32,50,,25.6,percent of total billed charges,50% of total billed charges,44.8,70,,35.84,percent of total billed charges,70% of total billed charges,31.03,48.48,,24.824,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,31.03,48.48,,24.824,percent of total billed charges,48.48% of total billed charges,44.8,70,,35.84,percent of total billed charges,70% of total billed charges,44.8,70,,35.84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,31.03,48.48,,24.824,percent of total billed charges,48.48% of total billed charges,57.6,90,,46.08,percent of total billed charges,90% of total billed charges,31.03,90,
NOC^ SOD PHOSPHATE,,,250,RC,J3490,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
NOC^ POT ACESTATE 2 MEQ,,,250,RC,J3490,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
NOC^ SOD CHL 23.4% 4 MEQ,,,250,RC,J3490,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
NOC^ TRACE ELEMENTS,,,250,RC,J3490,HCPCS,outpatient,1,UN,59,35.40,,35.4,60,,28.32,percent of total billed charges,60% of total billed charges,28.32,48,,22.656,percent of total billed charges,48% of total billed charges,29.5,50,,23.6,percent of total billed charges,50% of total billed charges,29.5,50,,23.6,percent of total billed charges,50% of total billed charges,29.5,50,,23.6,percent of total billed charges,50% of total billed charges,29.5,50,,23.6,percent of total billed charges,50% of total billed charges,41.3,70,,33.04,percent of total billed charges,70% of total billed charges,28.6,48.48,,22.88,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,28.6,48.48,,22.88,percent of total billed charges,48.48% of total billed charges,41.3,70,,33.04,percent of total billed charges,70% of total billed charges,41.3,70,,33.04,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,28.6,48.48,,22.88,percent of total billed charges,48.48% of total billed charges,53.1,90,,42.48,percent of total billed charges,90% of total billed charges,28.6,90,
NOC^ PANTOPRAZOLE 40MG SUSP,,,250,RC,J3490,HCPCS,outpatient,1,UN,77,46.20,,46.2,60,,36.96,percent of total billed charges,60% of total billed charges,36.96,48,,29.568,percent of total billed charges,48% of total billed charges,38.5,50,,30.8,percent of total billed charges,50% of total billed charges,38.5,50,,30.8,percent of total billed charges,50% of total billed charges,38.5,50,,30.8,percent of total billed charges,50% of total billed charges,38.5,50,,30.8,percent of total billed charges,50% of total billed charges,53.9,70,,43.12,percent of total billed charges,70% of total billed charges,37.33,48.48,,29.864,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,37.33,48.48,,29.864,percent of total billed charges,48.48% of total billed charges,53.9,70,,43.12,percent of total billed charges,70% of total billed charges,53.9,70,,43.12,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,37.33,48.48,,29.864,percent of total billed charges,48.48% of total billed charges,69.3,90,,55.44,percent of total billed charges,90% of total billed charges,37.33,90,
DILAUDID INJ 2MG/ML,,,636,RC,J1171,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
NOC^ FENTANYL PAT (12MCG/HR),,,250,RC,J3490,HCPCS,outpatient,1,UN,82,49.20,,49.2,60,,39.36,percent of total billed charges,60% of total billed charges,39.36,48,,31.488,percent of total billed charges,48% of total billed charges,41,50,,32.8,percent of total billed charges,50% of total billed charges,41,50,,32.8,percent of total billed charges,50% of total billed charges,41,50,,32.8,percent of total billed charges,50% of total billed charges,41,50,,32.8,percent of total billed charges,50% of total billed charges,57.4,70,,45.92,percent of total billed charges,70% of total billed charges,39.75,48.48,,31.8,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,39.75,48.48,,31.8,percent of total billed charges,48.48% of total billed charges,57.4,70,,45.92,percent of total billed charges,70% of total billed charges,57.4,70,,45.92,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,39.75,48.48,,31.8,percent of total billed charges,48.48% of total billed charges,73.8,90,,59.04,percent of total billed charges,90% of total billed charges,39.75,90,
NOC^ SITAGLIPTIN TAB 50 MG,,,250,RC,J3490,HCPCS,outpatient,1,UN,80,48.00,,48,60,,38.4,percent of total billed charges,60% of total billed charges,38.4,48,,30.72,percent of total billed charges,48% of total billed charges,40,50,,32,percent of total billed charges,50% of total billed charges,40,50,,32,percent of total billed charges,50% of total billed charges,40,50,,32,percent of total billed charges,50% of total billed charges,40,50,,32,percent of total billed charges,50% of total billed charges,56,70,,44.8,percent of total billed charges,70% of total billed charges,38.78,48.48,,31.024,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,38.78,48.48,,31.024,percent of total billed charges,48.48% of total billed charges,56,70,,44.8,percent of total billed charges,70% of total billed charges,56,70,,44.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,38.78,48.48,,31.024,percent of total billed charges,48.48% of total billed charges,72,90,,57.6,percent of total billed charges,90% of total billed charges,38.78,90,
FUROSEMIDE INJ 100MG/10ML,,,250,RC,,,outpatient,,,24,14.40,,14.4,60,,11.52,percent of total billed charges,60% of total billed charges,11.52,48,,9.216,percent of total billed charges,48% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,21.6,90,,17.28,percent of total billed charges,90% of total billed charges,11.64,90,
CARDENE 20MG/200ML PREMIX,,,636,RC,J3490,HCPCS,outpatient,1,UN,488,292.80,,292.8,60,,234.24,percent of total billed charges,60% of total billed charges,234.24,48,,187.392,percent of total billed charges,48% of total billed charges,244,50,,195.2,percent of total billed charges,50% of total billed charges,244,50,,195.2,percent of total billed charges,50% of total billed charges,244,50,,195.2,percent of total billed charges,50% of total billed charges,244,50,,195.2,percent of total billed charges,50% of total billed charges,341.6,70,,273.28,percent of total billed charges,70% of total billed charges,236.58,48.48,,189.264,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,236.58,48.48,,189.264,percent of total billed charges,48.48% of total billed charges,341.6,70,,273.28,percent of total billed charges,70% of total billed charges,341.6,70,,273.28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,236.58,48.48,,189.264,percent of total billed charges,48.48% of total billed charges,439.2,90,,351.36,percent of total billed charges,90% of total billed charges,48.48,439.2,
PERFOROMIST NEB 20 MCG,,,250,RC,,,outpatient,,,90,54.00,,54,60,,43.2,percent of total billed charges,60% of total billed charges,43.2,48,,34.56,percent of total billed charges,48% of total billed charges,45,50,,36,percent of total billed charges,50% of total billed charges,45,50,,36,percent of total billed charges,50% of total billed charges,45,50,,36,percent of total billed charges,50% of total billed charges,45,50,,36,percent of total billed charges,50% of total billed charges,63,70,,50.4,percent of total billed charges,70% of total billed charges,43.63,48.48,,34.904,percent of total billed charges,48.48% of total billed charges,43.63,48.48,,34.904,percent of total billed charges,48.48% of total billed charges,43.63,48.48,,34.904,percent of total billed charges,48.48% of total billed charges,63,70,,50.4,percent of total billed charges,70% of total billed charges,63,70,,50.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,43.63,48.48,,34.904,percent of total billed charges,48.48% of total billed charges,81,90,,64.8,percent of total billed charges,90% of total billed charges,43.63,90,
POT CHLORIDE 20 MEQ/100 ML PREMIX,,,250,RC,J3480,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,0.17,100,,,fee schedule,100% of bcbs custom fee schedule,0.17,100,,,fee schedule,100% of bcbs custom fee schedule,0.19,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
POT CHLORIDE 40 MEQ/100 ML,,,250,RC,,,outpatient,,,23,13.80,,13.8,60,,11.04,percent of total billed charges,60% of total billed charges,11.04,48,,8.832,percent of total billed charges,48% of total billed charges,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,16.1,70,,12.88,percent of total billed charges,70% of total billed charges,11.15,48.48,,8.92,percent of total billed charges,48.48% of total billed charges,11.15,48.48,,8.92,percent of total billed charges,48.48% of total billed charges,11.15,48.48,,8.92,percent of total billed charges,48.48% of total billed charges,16.1,70,,12.88,percent of total billed charges,70% of total billed charges,16.1,70,,12.88,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,11.15,48.48,,8.92,percent of total billed charges,48.48% of total billed charges,20.7,90,,16.56,percent of total billed charges,90% of total billed charges,11.15,90,
NOC^ PHENOL SWAB 1 APP,,,250,RC,J3490,HCPCS,outpatient,1,UN,22,13.20,,13.2,60,,10.56,percent of total billed charges,60% of total billed charges,10.56,48,,8.448,percent of total billed charges,48% of total billed charges,11,50,,8.8,percent of total billed charges,50% of total billed charges,11,50,,8.8,percent of total billed charges,50% of total billed charges,11,50,,8.8,percent of total billed charges,50% of total billed charges,11,50,,8.8,percent of total billed charges,50% of total billed charges,15.4,70,,12.32,percent of total billed charges,70% of total billed charges,10.67,48.48,,8.536,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,10.67,48.48,,8.536,percent of total billed charges,48.48% of total billed charges,15.4,70,,12.32,percent of total billed charges,70% of total billed charges,15.4,70,,12.32,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,10.67,48.48,,8.536,percent of total billed charges,48.48% of total billed charges,19.8,90,,15.84,percent of total billed charges,90% of total billed charges,10.67,90,
ROCURONIUM BROM 50 MG/5ML,,,250,RC,,,outpatient,,,40,24.00,,24,60,,19.2,percent of total billed charges,60% of total billed charges,19.2,48,,15.36,percent of total billed charges,48% of total billed charges,20,50,,16,percent of total billed charges,50% of total billed charges,20,50,,16,percent of total billed charges,50% of total billed charges,20,50,,16,percent of total billed charges,50% of total billed charges,20,50,,16,percent of total billed charges,50% of total billed charges,28,70,,22.4,percent of total billed charges,70% of total billed charges,19.39,48.48,,15.512,percent of total billed charges,48.48% of total billed charges,19.39,48.48,,15.512,percent of total billed charges,48.48% of total billed charges,19.39,48.48,,15.512,percent of total billed charges,48.48% of total billed charges,28,70,,22.4,percent of total billed charges,70% of total billed charges,28,70,,22.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,19.39,48.48,,15.512,percent of total billed charges,48.48% of total billed charges,36,90,,28.8,percent of total billed charges,90% of total billed charges,19.39,90,
DIPRIVAN INJ 10 MG,,,250,RC,,,outpatient,,,29,17.40,,17.4,60,,13.92,percent of total billed charges,60% of total billed charges,13.92,48,,11.136,percent of total billed charges,48% of total billed charges,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,20.3,70,,16.24,percent of total billed charges,70% of total billed charges,14.06,48.48,,11.248,percent of total billed charges,48.48% of total billed charges,14.06,48.48,,11.248,percent of total billed charges,48.48% of total billed charges,14.06,48.48,,11.248,percent of total billed charges,48.48% of total billed charges,20.3,70,,16.24,percent of total billed charges,70% of total billed charges,20.3,70,,16.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,14.06,48.48,,11.248,percent of total billed charges,48.48% of total billed charges,26.1,90,,20.88,percent of total billed charges,90% of total billed charges,14.06,90,
DALBAVANCIN INJ 500 MG,,,636,RC,J0875,HCPCS,outpatient,1,UN,3908,2344.80,,2344.8,60,,1875.84,percent of total billed charges,60% of total billed charges,1875.84,48,,1500.672,percent of total billed charges,48% of total billed charges,16.93,100,,,fee schedule,100% of bcbs custom fee schedule,16.93,100,,,fee schedule,100% of bcbs custom fee schedule,18.79,111,,,fee schedule,111% of bcbs custom fee schedule,1954,50,,1563.2,percent of total billed charges,50% of total billed charges,2735.6,70,,2188.48,percent of total billed charges,70% of total billed charges,1894.6,48.48,,1515.68,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,1894.6,48.48,,1515.68,percent of total billed charges,48.48% of total billed charges,2735.6,70,,2188.48,percent of total billed charges,70% of total billed charges,2735.6,70,,2188.48,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,1894.6,48.48,,1515.68,percent of total billed charges,48.48% of total billed charges,3517.2,90,,2813.76,percent of total billed charges,90% of total billed charges,48.48,3517.2,
TEFLARO INJ 400 MG,,,636,RC,J0712,HCPCS,outpatient,1,UN,1016,609.60,,609.6,60,,487.68,percent of total billed charges,60% of total billed charges,487.68,48,,390.144,percent of total billed charges,48% of total billed charges,3.65,100,,,fee schedule,100% of bcbs custom fee schedule,3.65,100,,,fee schedule,100% of bcbs custom fee schedule,4.05,111,,,fee schedule,111% of bcbs custom fee schedule,508,50,,406.4,percent of total billed charges,50% of total billed charges,711.2,70,,568.96,percent of total billed charges,70% of total billed charges,492.56,48.48,,394.048,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,492.56,48.48,,394.048,percent of total billed charges,48.48% of total billed charges,711.2,70,,568.96,percent of total billed charges,70% of total billed charges,711.2,70,,568.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,492.56,48.48,,394.048,percent of total billed charges,48.48% of total billed charges,914.4,90,,731.52,percent of total billed charges,90% of total billed charges,48.48,914.4,
TEFLARO INJ 600MG,,,636,RC,J0712,HCPCS,outpatient,60,UN,1119.6,671.76,,671.76,60,,537.408,percent of total billed charges,60% of total billed charges,537.41,48,,429.928,percent of total billed charges,48% of total billed charges,3.65,100,,,fee schedule,100% of bcbs custom fee schedule,3.65,100,,,fee schedule,100% of bcbs custom fee schedule,4.05,111,,,fee schedule,111% of bcbs custom fee schedule,559.8,50,,447.84,percent of total billed charges,50% of total billed charges,783.72,70,,626.976,percent of total billed charges,70% of total billed charges,542.78,48.48,,434.224,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,542.78,48.48,,434.224,percent of total billed charges,48.48% of total billed charges,783.72,70,,626.976,percent of total billed charges,70% of total billed charges,783.72,70,,626.976,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,542.78,48.48,,434.224,percent of total billed charges,48.48% of total billed charges,1007.64,90,,806.112,percent of total billed charges,90% of total billed charges,48.48,1007.64,
LEVETIRACETAM 500 MG PREMIX,,,636,RC,J1953,HCPCS,outpatient,1,UN,68,40.80,,40.8,60,,32.64,percent of total billed charges,60% of total billed charges,32.64,48,,26.112,percent of total billed charges,48% of total billed charges,0.13,100,,,fee schedule,100% of bcbs custom fee schedule,0.13,100,,,fee schedule,100% of bcbs custom fee schedule,0.14,111,,,fee schedule,111% of bcbs custom fee schedule,34,50,,27.2,percent of total billed charges,50% of total billed charges,47.6,70,,38.08,percent of total billed charges,70% of total billed charges,32.97,48.48,,26.376,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,32.97,48.48,,26.376,percent of total billed charges,48.48% of total billed charges,47.6,70,,38.08,percent of total billed charges,70% of total billed charges,47.6,70,,38.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,32.97,48.48,,26.376,percent of total billed charges,48.48% of total billed charges,61.2,90,,48.96,percent of total billed charges,90% of total billed charges,32.97,90,
CETRAXAL OTIC 0.2% [0.25 mL],,,259,RC,,,outpatient,,,186,111.60,,111.6,60,,89.28,percent of total billed charges,60% of total billed charges,89.28,48,,71.424,percent of total billed charges,48% of total billed charges,93,50,,74.4,percent of total billed charges,50% of total billed charges,93,50,,74.4,percent of total billed charges,50% of total billed charges,93,50,,74.4,percent of total billed charges,50% of total billed charges,93,50,,74.4,percent of total billed charges,50% of total billed charges,130.2,70,,104.16,percent of total billed charges,70% of total billed charges,90.17,48.48,,72.136,percent of total billed charges,48.48% of total billed charges,90.17,48.48,,72.136,percent of total billed charges,48.48% of total billed charges,90.17,48.48,,72.136,percent of total billed charges,48.48% of total billed charges,130.2,70,,104.16,percent of total billed charges,70% of total billed charges,130.2,70,,104.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,90.17,48.48,,72.136,percent of total billed charges,48.48% of total billed charges,167.4,90,,133.92,percent of total billed charges,90% of total billed charges,48.48,167.4,
NOC^ BRILINTA TAB 90 MG,,,259,RC,J8499,HCPCS,outpatient,1,UN,33,19.80,,19.8,60,,15.84,percent of total billed charges,60% of total billed charges,15.84,48,,12.672,percent of total billed charges,48% of total billed charges,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,23.1,70,,18.48,percent of total billed charges,70% of total billed charges,16,48.48,,12.8,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,16,48.48,,12.8,percent of total billed charges,48.48% of total billed charges,23.1,70,,18.48,percent of total billed charges,70% of total billed charges,23.1,70,,18.48,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,16,48.48,,12.8,percent of total billed charges,48.48% of total billed charges,29.7,90,,23.76,percent of total billed charges,90% of total billed charges,16,90,
NOC^ CLINDAMYCIN VAGINAL CRM 2,,,259,RC,J3490,HCPCS,outpatient,1,UN,522,313.20,,313.2,60,,250.56,percent of total billed charges,60% of total billed charges,250.56,48,,200.448,percent of total billed charges,48% of total billed charges,261,50,,208.8,percent of total billed charges,50% of total billed charges,261,50,,208.8,percent of total billed charges,50% of total billed charges,261,50,,208.8,percent of total billed charges,50% of total billed charges,261,50,,208.8,percent of total billed charges,50% of total billed charges,365.4,70,,292.32,percent of total billed charges,70% of total billed charges,253.07,48.48,,202.456,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,253.07,48.48,,202.456,percent of total billed charges,48.48% of total billed charges,365.4,70,,292.32,percent of total billed charges,70% of total billed charges,365.4,70,,292.32,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,253.07,48.48,,202.456,percent of total billed charges,48.48% of total billed charges,469.8,90,,375.84,percent of total billed charges,90% of total billed charges,48.48,469.8,
AQUACEL AG DRESSING,,,279,RC,A6197,HCPCS,outpatient,,,80,48.00,,48,60,,38.4,percent of total billed charges,60% of total billed charges,38.4,48,,30.72,percent of total billed charges,48% of total billed charges,40,50,,32,percent of total billed charges,50% of total billed charges,40,50,,32,percent of total billed charges,50% of total billed charges,40,50,,32,percent of total billed charges,50% of total billed charges,40,50,,32,percent of total billed charges,50% of total billed charges,56,70,,44.8,percent of total billed charges,70% of total billed charges,38.78,48.48,,31.024,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,38.78,48.48,,31.024,percent of total billed charges,48.48% of total billed charges,56,70,,44.8,percent of total billed charges,70% of total billed charges,56,70,,44.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,38.78,48.48,,31.024,percent of total billed charges,48.48% of total billed charges,72,90,,57.6,percent of total billed charges,90% of total billed charges,38.78,90,
COLISTIMETHATE INJ 150 MG,,,636,RC,J0770,HCPCS,outpatient,1,UN,135,81.00,,81,60,,64.8,percent of total billed charges,60% of total billed charges,64.8,48,,51.84,percent of total billed charges,48% of total billed charges,17.18,100,,,fee schedule,100% of bcbs custom fee schedule,17.18,100,,,fee schedule,100% of bcbs custom fee schedule,19.07,111,,,fee schedule,111% of bcbs custom fee schedule,67.5,50,,54,percent of total billed charges,50% of total billed charges,94.5,70,,75.6,percent of total billed charges,70% of total billed charges,65.45,48.48,,52.36,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,65.45,48.48,,52.36,percent of total billed charges,48.48% of total billed charges,94.5,70,,75.6,percent of total billed charges,70% of total billed charges,94.5,70,,75.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,65.45,48.48,,52.36,percent of total billed charges,48.48% of total billed charges,121.5,90,,97.2,percent of total billed charges,90% of total billed charges,48.48,121.5,
NOC^ MONSEL'S PASTE,,,250,RC,J3490,HCPCS,outpatient,1,UN,73,43.80,,43.8,60,,35.04,percent of total billed charges,60% of total billed charges,35.04,48,,28.032,percent of total billed charges,48% of total billed charges,36.5,50,,29.2,percent of total billed charges,50% of total billed charges,36.5,50,,29.2,percent of total billed charges,50% of total billed charges,36.5,50,,29.2,percent of total billed charges,50% of total billed charges,36.5,50,,29.2,percent of total billed charges,50% of total billed charges,51.1,70,,40.88,percent of total billed charges,70% of total billed charges,35.39,48.48,,28.312,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,35.39,48.48,,28.312,percent of total billed charges,48.48% of total billed charges,51.1,70,,40.88,percent of total billed charges,70% of total billed charges,51.1,70,,40.88,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,35.39,48.48,,28.312,percent of total billed charges,48.48% of total billed charges,65.7,90,,52.56,percent of total billed charges,90% of total billed charges,35.39,90,
PHENYLEPHRINE INJ 10 MG/ML,,,636,RC,J2371,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
NOC^ CETAPHIL CLEANSER,,,259,RC,J3490,HCPCS,outpatient,1,UN,16,9.60,,9.6,60,,7.68,percent of total billed charges,60% of total billed charges,7.68,48,,6.144,percent of total billed charges,48% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,11.2,70,,8.96,percent of total billed charges,70% of total billed charges,7.76,48.48,,6.208,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,7.76,48.48,,6.208,percent of total billed charges,48.48% of total billed charges,11.2,70,,8.96,percent of total billed charges,70% of total billed charges,11.2,70,,8.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,7.76,48.48,,6.208,percent of total billed charges,48.48% of total billed charges,14.4,90,,11.52,percent of total billed charges,90% of total billed charges,7.76,90,
PEPCID IV PREMIX 20 MG/50 ML,,,636,RC,,,outpatient,,,38,22.80,,22.8,60,,18.24,percent of total billed charges,60% of total billed charges,18.24,48,,14.592,percent of total billed charges,48% of total billed charges,19,50,,15.2,percent of total billed charges,50% of total billed charges,19,50,,15.2,percent of total billed charges,50% of total billed charges,19,50,,15.2,percent of total billed charges,50% of total billed charges,19,50,,15.2,percent of total billed charges,50% of total billed charges,26.6,70,,21.28,percent of total billed charges,70% of total billed charges,18.42,48.48,,14.736,percent of total billed charges,48.48% of total billed charges,18.42,48.48,,14.736,percent of total billed charges,48.48% of total billed charges,18.42,48.48,,14.736,percent of total billed charges,48.48% of total billed charges,26.6,70,,21.28,percent of total billed charges,70% of total billed charges,26.6,70,,21.28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,18.42,48.48,,14.736,percent of total billed charges,48.48% of total billed charges,34.2,90,,27.36,percent of total billed charges,90% of total billed charges,18.42,90,
LEVOFLOXACIN 750 MG IV PMX,,,636,RC,J1956,HCPCS,outpatient,3,UN,68.01,40.81,,40.81,60,,32.648,percent of total billed charges,60% of total billed charges,32.64,48,,26.112,percent of total billed charges,48% of total billed charges,0.44,100,,,fee schedule,100% of bcbs custom fee schedule,0.44,100,,,fee schedule,100% of bcbs custom fee schedule,0.49,111,,,fee schedule,111% of bcbs custom fee schedule,34.01,50,,27.208,percent of total billed charges,50% of total billed charges,47.61,70,,38.088,percent of total billed charges,70% of total billed charges,32.97,48.48,,26.376,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,32.97,48.48,,26.376,percent of total billed charges,48.48% of total billed charges,47.61,70,,38.088,percent of total billed charges,70% of total billed charges,47.61,70,,38.088,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,32.97,48.48,,26.376,percent of total billed charges,48.48% of total billed charges,61.21,90,,48.968,percent of total billed charges,90% of total billed charges,32.97,90,
RENVELA TAB 800 MG,,,250,RC,,,outpatient,,,29,17.40,,17.4,60,,13.92,percent of total billed charges,60% of total billed charges,13.92,48,,11.136,percent of total billed charges,48% of total billed charges,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,20.3,70,,16.24,percent of total billed charges,70% of total billed charges,14.06,48.48,,11.248,percent of total billed charges,48.48% of total billed charges,14.06,48.48,,11.248,percent of total billed charges,48.48% of total billed charges,14.06,48.48,,11.248,percent of total billed charges,48.48% of total billed charges,20.3,70,,16.24,percent of total billed charges,70% of total billed charges,20.3,70,,16.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,14.06,48.48,,11.248,percent of total billed charges,48.48% of total billed charges,26.1,90,,20.88,percent of total billed charges,90% of total billed charges,14.06,90,
LAMICTAL ODT 25 MG,,,250,RC,,,outpatient,,,13,7.80,,7.8,60,,6.24,percent of total billed charges,60% of total billed charges,6.24,48,,4.992,percent of total billed charges,48% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,9.1,70,,7.28,percent of total billed charges,70% of total billed charges,6.3,48.48,,5.04,percent of total billed charges,48.48% of total billed charges,6.3,48.48,,5.04,percent of total billed charges,48.48% of total billed charges,6.3,48.48,,5.04,percent of total billed charges,48.48% of total billed charges,9.1,70,,7.28,percent of total billed charges,70% of total billed charges,9.1,70,,7.28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,6.3,48.48,,5.04,percent of total billed charges,48.48% of total billed charges,11.7,90,,9.36,percent of total billed charges,90% of total billed charges,6.3,90,
GARDASIL 9 INJ,,,250,RC,,,outpatient,,,329,197.40,,197.4,60,,157.92,percent of total billed charges,60% of total billed charges,157.92,48,,126.336,percent of total billed charges,48% of total billed charges,164.5,50,,131.6,percent of total billed charges,50% of total billed charges,164.5,50,,131.6,percent of total billed charges,50% of total billed charges,164.5,50,,131.6,percent of total billed charges,50% of total billed charges,164.5,50,,131.6,percent of total billed charges,50% of total billed charges,230.3,70,,184.24,percent of total billed charges,70% of total billed charges,159.5,48.48,,127.6,percent of total billed charges,48.48% of total billed charges,159.5,48.48,,127.6,percent of total billed charges,48.48% of total billed charges,159.5,48.48,,127.6,percent of total billed charges,48.48% of total billed charges,230.3,70,,184.24,percent of total billed charges,70% of total billed charges,230.3,70,,184.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,159.5,48.48,,127.6,percent of total billed charges,48.48% of total billed charges,296.1,90,,236.88,percent of total billed charges,90% of total billed charges,48.48,296.1,
MMR-II INJ,43601416,CDM,250,RC,90707,HCPCS,outpatient,1,UN,200,120.00,,120,60,,96,percent of total billed charges,60% of total billed charges,96,48,,76.8,percent of total billed charges,48% of total billed charges,89.26,100,,,fee schedule,100% of bcbs custom fee schedule,89.26,100,,,fee schedule,100% of bcbs custom fee schedule,99.08,111,,,fee schedule,111% of bcbs custom fee schedule,100,50,,80,percent of total billed charges,50% of total billed charges,140,70,,112,percent of total billed charges,70% of total billed charges,96.96,48.48,,77.568,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,96.96,48.48,,77.568,percent of total billed charges,48.48% of total billed charges,140,70,,112,percent of total billed charges,70% of total billed charges,140,70,,112,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,96.96,48.48,,77.568,percent of total billed charges,48.48% of total billed charges,180,90,,144,percent of total billed charges,90% of total billed charges,48.48,180,
VARICELLA VACCINE,,,250,RC,90396,HCPCS,outpatient,1,UN,342,205.20,,205.2,60,,164.16,percent of total billed charges,60% of total billed charges,164.16,48,,131.328,percent of total billed charges,48% of total billed charges,2056.72,100,,,fee schedule,100% of bcbs custom fee schedule,2056.72,100,,,fee schedule,100% of bcbs custom fee schedule,2282.96,111,,,fee schedule,111% of bcbs custom fee schedule,171,50,,136.8,percent of total billed charges,50% of total billed charges,239.4,70,,191.52,percent of total billed charges,70% of total billed charges,165.8,48.48,,132.64,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,165.8,48.48,,132.64,percent of total billed charges,48.48% of total billed charges,239.4,70,,191.52,percent of total billed charges,70% of total billed charges,239.4,70,,191.52,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,165.8,48.48,,132.64,percent of total billed charges,48.48% of total billed charges,307.8,90,,246.24,percent of total billed charges,90% of total billed charges,48.48,307.8,
GENTAMICIN 80MG PREMIX IVPB,43601682,CDM,636,RC,J1580,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,1.97,100,,,fee schedule,100% of bcbs custom fee schedule,1.97,100,,,fee schedule,100% of bcbs custom fee schedule,2.19,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
BEXSERO INJ 0.5 ML,43601402,CDM,636,RC,90620,HCPCS,outpatient,1,UN,460,276.00,,276,60,,220.8,percent of total billed charges,60% of total billed charges,220.8,48,,176.64,percent of total billed charges,48% of total billed charges,204.2,100,,,fee schedule,100% of bcbs custom fee schedule,204.2,100,,,fee schedule,100% of bcbs custom fee schedule,226.66,111,,,fee schedule,111% of bcbs custom fee schedule,230,50,,184,percent of total billed charges,50% of total billed charges,322,70,,257.6,percent of total billed charges,70% of total billed charges,223.01,48.48,,178.408,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,223.01,48.48,,178.408,percent of total billed charges,48.48% of total billed charges,322,70,,257.6,percent of total billed charges,70% of total billed charges,322,70,,257.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,223.01,48.48,,178.408,percent of total billed charges,48.48% of total billed charges,414,90,,331.2,percent of total billed charges,90% of total billed charges,48.48,414,
PHYTONADIONE ORAL SOL 5 ML,,,250,RC,,,outpatient,,,72,43.20,,43.2,60,,34.56,percent of total billed charges,60% of total billed charges,34.56,48,,27.648,percent of total billed charges,48% of total billed charges,36,50,,28.8,percent of total billed charges,50% of total billed charges,36,50,,28.8,percent of total billed charges,50% of total billed charges,36,50,,28.8,percent of total billed charges,50% of total billed charges,36,50,,28.8,percent of total billed charges,50% of total billed charges,50.4,70,,40.32,percent of total billed charges,70% of total billed charges,34.91,48.48,,27.928,percent of total billed charges,48.48% of total billed charges,34.91,48.48,,27.928,percent of total billed charges,48.48% of total billed charges,34.91,48.48,,27.928,percent of total billed charges,48.48% of total billed charges,50.4,70,,40.32,percent of total billed charges,70% of total billed charges,50.4,70,,40.32,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,34.91,48.48,,27.928,percent of total billed charges,48.48% of total billed charges,64.8,90,,51.84,percent of total billed charges,90% of total billed charges,34.91,90,
BRETHINE,,,250,RC,,,outpatient,,,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
PHENERGAN GEL,,,250,RC,,,outpatient,,,35,21.00,,21,60,,16.8,percent of total billed charges,60% of total billed charges,16.8,48,,13.44,percent of total billed charges,48% of total billed charges,17.5,50,,14,percent of total billed charges,50% of total billed charges,17.5,50,,14,percent of total billed charges,50% of total billed charges,17.5,50,,14,percent of total billed charges,50% of total billed charges,17.5,50,,14,percent of total billed charges,50% of total billed charges,24.5,70,,19.6,percent of total billed charges,70% of total billed charges,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,24.5,70,,19.6,percent of total billed charges,70% of total billed charges,24.5,70,,19.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,31.5,90,,25.2,percent of total billed charges,90% of total billed charges,16.97,90,
Voltaren Gel 150G,,,250,RC,,,outpatient,1,UN,97,58.20,,58.2,60,,46.56,percent of total billed charges,60% of total billed charges,46.56,48,,37.248,percent of total billed charges,48% of total billed charges,48.5,50,,38.8,percent of total billed charges,50% of total billed charges,48.5,50,,38.8,percent of total billed charges,50% of total billed charges,48.5,50,,38.8,percent of total billed charges,50% of total billed charges,48.5,50,,38.8,percent of total billed charges,50% of total billed charges,67.9,70,,54.32,percent of total billed charges,70% of total billed charges,47.03,48.48,,37.624,percent of total billed charges,48.48% of total billed charges,47.03,48.48,,37.624,percent of total billed charges,48.48% of total billed charges,47.03,48.48,,37.624,percent of total billed charges,48.48% of total billed charges,67.9,70,,54.32,percent of total billed charges,70% of total billed charges,67.9,70,,54.32,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,47.03,48.48,,37.624,percent of total billed charges,48.48% of total billed charges,87.3,90,,69.84,percent of total billed charges,90% of total billed charges,47.03,90,
LINZESS 145 MCG CAPSULE,,,250,RC,,,outpatient,,,75,45.00,,45,60,,36,percent of total billed charges,60% of total billed charges,36,48,,28.8,percent of total billed charges,48% of total billed charges,37.5,50,,30,percent of total billed charges,50% of total billed charges,37.5,50,,30,percent of total billed charges,50% of total billed charges,37.5,50,,30,percent of total billed charges,50% of total billed charges,37.5,50,,30,percent of total billed charges,50% of total billed charges,52.5,70,,42,percent of total billed charges,70% of total billed charges,36.36,48.48,,29.088,percent of total billed charges,48.48% of total billed charges,36.36,48.48,,29.088,percent of total billed charges,48.48% of total billed charges,36.36,48.48,,29.088,percent of total billed charges,48.48% of total billed charges,52.5,70,,42,percent of total billed charges,70% of total billed charges,52.5,70,,42,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,36.36,48.48,,29.088,percent of total billed charges,48.48% of total billed charges,67.5,90,,54,percent of total billed charges,90% of total billed charges,36.36,90,
PREVNAR 13 VACCINE,43601409,CDM,636,RC,90670,HCPCS,outpatient,1,UN,525,315.00,,315,60,,252,percent of total billed charges,60% of total billed charges,252,48,,201.6,percent of total billed charges,48% of total billed charges,253.15,100,,,fee schedule,100% of bcbs custom fee schedule,253.15,100,,,fee schedule,100% of bcbs custom fee schedule,281,111,,,fee schedule,111% of bcbs custom fee schedule,262.5,50,,210,percent of total billed charges,50% of total billed charges,367.5,70,,294,percent of total billed charges,70% of total billed charges,254.52,48.48,,203.616,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,254.52,48.48,,203.616,percent of total billed charges,48.48% of total billed charges,367.5,70,,294,percent of total billed charges,70% of total billed charges,367.5,70,,294,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,254.52,48.48,,203.616,percent of total billed charges,48.48% of total billed charges,472.5,90,,378,percent of total billed charges,90% of total billed charges,48.48,472.5,
CEFUROXIME 1.5GM,,,636,RC,,,outpatient,,,57,34.20,,34.2,60,,27.36,percent of total billed charges,60% of total billed charges,27.36,48,,21.888,percent of total billed charges,48% of total billed charges,28.5,50,,22.8,percent of total billed charges,50% of total billed charges,28.5,50,,22.8,percent of total billed charges,50% of total billed charges,28.5,50,,22.8,percent of total billed charges,50% of total billed charges,28.5,50,,22.8,percent of total billed charges,50% of total billed charges,39.9,70,,31.92,percent of total billed charges,70% of total billed charges,27.63,48.48,,22.104,percent of total billed charges,48.48% of total billed charges,27.63,48.48,,22.104,percent of total billed charges,48.48% of total billed charges,27.63,48.48,,22.104,percent of total billed charges,48.48% of total billed charges,39.9,70,,31.92,percent of total billed charges,70% of total billed charges,39.9,70,,31.92,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,27.63,48.48,,22.104,percent of total billed charges,48.48% of total billed charges,51.3,90,,41.04,percent of total billed charges,90% of total billed charges,27.63,90,
MEMANTINE XR 14 MG,,,250,RC,,,outpatient,,,75,45.00,,45,60,,36,percent of total billed charges,60% of total billed charges,36,48,,28.8,percent of total billed charges,48% of total billed charges,37.5,50,,30,percent of total billed charges,50% of total billed charges,37.5,50,,30,percent of total billed charges,50% of total billed charges,37.5,50,,30,percent of total billed charges,50% of total billed charges,37.5,50,,30,percent of total billed charges,50% of total billed charges,52.5,70,,42,percent of total billed charges,70% of total billed charges,36.36,48.48,,29.088,percent of total billed charges,48.48% of total billed charges,36.36,48.48,,29.088,percent of total billed charges,48.48% of total billed charges,36.36,48.48,,29.088,percent of total billed charges,48.48% of total billed charges,52.5,70,,42,percent of total billed charges,70% of total billed charges,52.5,70,,42,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,36.36,48.48,,29.088,percent of total billed charges,48.48% of total billed charges,67.5,90,,54,percent of total billed charges,90% of total billed charges,36.36,90,
BUDESONIDE/FORMOTEROL INH 160/4.5,,,250,RC,,,outpatient,1,UN,1624,974.40,,974.4,60,,779.52,percent of total billed charges,60% of total billed charges,779.52,48,,623.616,percent of total billed charges,48% of total billed charges,812,50,,649.6,percent of total billed charges,50% of total billed charges,812,50,,649.6,percent of total billed charges,50% of total billed charges,812,50,,649.6,percent of total billed charges,50% of total billed charges,812,50,,649.6,percent of total billed charges,50% of total billed charges,1136.8,70,,909.44,percent of total billed charges,70% of total billed charges,787.32,48.48,,629.856,percent of total billed charges,48.48% of total billed charges,787.32,48.48,,629.856,percent of total billed charges,48.48% of total billed charges,787.32,48.48,,629.856,percent of total billed charges,48.48% of total billed charges,1136.8,70,,909.44,percent of total billed charges,70% of total billed charges,1136.8,70,,909.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,787.32,48.48,,629.856,percent of total billed charges,48.48% of total billed charges,1461.6,90,,1169.28,percent of total billed charges,90% of total billed charges,48.48,1461.6,
NOC^ ANORO,,,250,RC,J3490,HCPCS,outpatient,1,UN,502,301.20,,301.2,60,,240.96,percent of total billed charges,60% of total billed charges,240.96,48,,192.768,percent of total billed charges,48% of total billed charges,251,50,,200.8,percent of total billed charges,50% of total billed charges,251,50,,200.8,percent of total billed charges,50% of total billed charges,251,50,,200.8,percent of total billed charges,50% of total billed charges,251,50,,200.8,percent of total billed charges,50% of total billed charges,351.4,70,,281.12,percent of total billed charges,70% of total billed charges,243.37,48.48,,194.696,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,243.37,48.48,,194.696,percent of total billed charges,48.48% of total billed charges,351.4,70,,281.12,percent of total billed charges,70% of total billed charges,351.4,70,,281.12,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,243.37,48.48,,194.696,percent of total billed charges,48.48% of total billed charges,451.8,90,,361.44,percent of total billed charges,90% of total billed charges,48.48,451.8,
DALBAVANCIN INJ 1000 MG,,,636,RC,J0875,HCPCS,outpatient,1,UN,7816,4689.60,,4689.6,60,,3751.68,percent of total billed charges,60% of total billed charges,3751.68,48,,3001.344,percent of total billed charges,48% of total billed charges,16.93,100,,,fee schedule,100% of bcbs custom fee schedule,16.93,100,,,fee schedule,100% of bcbs custom fee schedule,18.79,111,,,fee schedule,111% of bcbs custom fee schedule,3908,50,,3126.4,percent of total billed charges,50% of total billed charges,5471.2,70,,4376.96,percent of total billed charges,70% of total billed charges,3789.2,48.48,,3031.36,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,3789.2,48.48,,3031.36,percent of total billed charges,48.48% of total billed charges,5471.2,70,,4376.96,percent of total billed charges,70% of total billed charges,5471.2,70,,4376.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,3789.2,48.48,,3031.36,percent of total billed charges,48.48% of total billed charges,7034.4,90,,5627.52,percent of total billed charges,90% of total billed charges,48.48,7034.4,
AQUAPHOR OINTMENT 14 0Z,,,259,RC,A9150,HCPCS,outpatient,1,UN,73,43.80,,43.8,60,,35.04,percent of total billed charges,60% of total billed charges,35.04,48,,28.032,percent of total billed charges,48% of total billed charges,36.5,50,,29.2,percent of total billed charges,50% of total billed charges,36.5,50,,29.2,percent of total billed charges,50% of total billed charges,36.5,50,,29.2,percent of total billed charges,50% of total billed charges,36.5,50,,29.2,percent of total billed charges,50% of total billed charges,51.1,70,,40.88,percent of total billed charges,70% of total billed charges,35.39,48.48,,28.312,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,35.39,48.48,,28.312,percent of total billed charges,48.48% of total billed charges,51.1,70,,40.88,percent of total billed charges,70% of total billed charges,51.1,70,,40.88,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,35.39,48.48,,28.312,percent of total billed charges,48.48% of total billed charges,65.7,90,,52.56,percent of total billed charges,90% of total billed charges,35.39,90,
DEXTROSE 50% 50 ML INJ,,,250,RC,,,outpatient,,,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
DEMECLOCYCLINE 150MG TAB,,,259,RC,,,outpatient,,,43,25.80,,25.8,60,,20.64,percent of total billed charges,60% of total billed charges,20.64,48,,16.512,percent of total billed charges,48% of total billed charges,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,30.1,70,,24.08,percent of total billed charges,70% of total billed charges,20.85,48.48,,16.68,percent of total billed charges,48.48% of total billed charges,20.85,48.48,,16.68,percent of total billed charges,48.48% of total billed charges,20.85,48.48,,16.68,percent of total billed charges,48.48% of total billed charges,30.1,70,,24.08,percent of total billed charges,70% of total billed charges,30.1,70,,24.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,20.85,48.48,,16.68,percent of total billed charges,48.48% of total billed charges,38.7,90,,30.96,percent of total billed charges,90% of total billed charges,20.85,90,
CLINDAYCIN TOP GEL 30 GM,,,259,RC,,,outpatient,,,415,249.00,,249,60,,199.2,percent of total billed charges,60% of total billed charges,199.2,48,,159.36,percent of total billed charges,48% of total billed charges,207.5,50,,166,percent of total billed charges,50% of total billed charges,207.5,50,,166,percent of total billed charges,50% of total billed charges,207.5,50,,166,percent of total billed charges,50% of total billed charges,207.5,50,,166,percent of total billed charges,50% of total billed charges,290.5,70,,232.4,percent of total billed charges,70% of total billed charges,201.19,48.48,,160.952,percent of total billed charges,48.48% of total billed charges,201.19,48.48,,160.952,percent of total billed charges,48.48% of total billed charges,201.19,48.48,,160.952,percent of total billed charges,48.48% of total billed charges,290.5,70,,232.4,percent of total billed charges,70% of total billed charges,290.5,70,,232.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,201.19,48.48,,160.952,percent of total billed charges,48.48% of total billed charges,373.5,90,,298.8,percent of total billed charges,90% of total billed charges,48.48,373.5,
SILVASORB GEL 1.5 OZ,,,250,RC,,,outpatient,1,UN,115,69.00,,69,60,,55.2,percent of total billed charges,60% of total billed charges,55.2,48,,44.16,percent of total billed charges,48% of total billed charges,57.5,50,,46,percent of total billed charges,50% of total billed charges,57.5,50,,46,percent of total billed charges,50% of total billed charges,57.5,50,,46,percent of total billed charges,50% of total billed charges,57.5,50,,46,percent of total billed charges,50% of total billed charges,80.5,70,,64.4,percent of total billed charges,70% of total billed charges,55.75,48.48,,44.6,percent of total billed charges,48.48% of total billed charges,55.75,48.48,,44.6,percent of total billed charges,48.48% of total billed charges,55.75,48.48,,44.6,percent of total billed charges,48.48% of total billed charges,80.5,70,,64.4,percent of total billed charges,70% of total billed charges,80.5,70,,64.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,55.75,48.48,,44.6,percent of total billed charges,48.48% of total billed charges,103.5,90,,82.8,percent of total billed charges,90% of total billed charges,48.48,103.5,
Tradjenta,,,250,RC,J3490,HCPCS,outpatient,1,UN,81,48.60,,48.6,60,,38.88,percent of total billed charges,60% of total billed charges,38.88,48,,31.104,percent of total billed charges,48% of total billed charges,40.5,50,,32.4,percent of total billed charges,50% of total billed charges,40.5,50,,32.4,percent of total billed charges,50% of total billed charges,40.5,50,,32.4,percent of total billed charges,50% of total billed charges,40.5,50,,32.4,percent of total billed charges,50% of total billed charges,56.7,70,,45.36,percent of total billed charges,70% of total billed charges,39.27,48.48,,31.416,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,39.27,48.48,,31.416,percent of total billed charges,48.48% of total billed charges,56.7,70,,45.36,percent of total billed charges,70% of total billed charges,56.7,70,,45.36,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,39.27,48.48,,31.416,percent of total billed charges,48.48% of total billed charges,72.9,90,,58.32,percent of total billed charges,90% of total billed charges,39.27,90,
AVYCAZ 2.5GM,,,636,RC,J0714,HCPCS,outpatient,5,UN,1723,1033.80,,1033.8,60,,827.04,percent of total billed charges,60% of total billed charges,827.04,48,,661.632,percent of total billed charges,48% of total billed charges,101.2,100,,,fee schedule,100% of bcbs custom fee schedule,101.2,100,,,fee schedule,100% of bcbs custom fee schedule,112.33,111,,,fee schedule,111% of bcbs custom fee schedule,861.5,50,,689.2,percent of total billed charges,50% of total billed charges,1206.1,70,,964.88,percent of total billed charges,70% of total billed charges,835.31,48.48,,668.248,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,835.31,48.48,,668.248,percent of total billed charges,48.48% of total billed charges,1206.1,70,,964.88,percent of total billed charges,70% of total billed charges,1206.1,70,,964.88,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,835.31,48.48,,668.248,percent of total billed charges,48.48% of total billed charges,1550.7,90,,1240.56,percent of total billed charges,90% of total billed charges,48.48,1550.7,
CEFEPIME INJ 1 GM,,,636,RC,J0692,HCPCS,outpatient,1,UN,29,17.40,,17.4,60,,13.92,percent of total billed charges,60% of total billed charges,13.92,48,,11.136,percent of total billed charges,48% of total billed charges,1.86,100,,,fee schedule,100% of bcbs custom fee schedule,1.86,100,,,fee schedule,100% of bcbs custom fee schedule,2.06,111,,,fee schedule,111% of bcbs custom fee schedule,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,20.3,70,,16.24,percent of total billed charges,70% of total billed charges,14.06,48.48,,11.248,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,14.06,48.48,,11.248,percent of total billed charges,48.48% of total billed charges,20.3,70,,16.24,percent of total billed charges,70% of total billed charges,20.3,70,,16.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,14.06,48.48,,11.248,percent of total billed charges,48.48% of total billed charges,26.1,90,,20.88,percent of total billed charges,90% of total billed charges,14.06,90,
DILTIAZEM INJ 125 MG/25 ML,,,250,RC,,,outpatient,,,55,33.00,,33,60,,26.4,percent of total billed charges,60% of total billed charges,26.4,48,,21.12,percent of total billed charges,48% of total billed charges,27.5,50,,22,percent of total billed charges,50% of total billed charges,27.5,50,,22,percent of total billed charges,50% of total billed charges,27.5,50,,22,percent of total billed charges,50% of total billed charges,27.5,50,,22,percent of total billed charges,50% of total billed charges,38.5,70,,30.8,percent of total billed charges,70% of total billed charges,26.66,48.48,,21.328,percent of total billed charges,48.48% of total billed charges,26.66,48.48,,21.328,percent of total billed charges,48.48% of total billed charges,26.66,48.48,,21.328,percent of total billed charges,48.48% of total billed charges,38.5,70,,30.8,percent of total billed charges,70% of total billed charges,38.5,70,,30.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,26.66,48.48,,21.328,percent of total billed charges,48.48% of total billed charges,49.5,90,,39.6,percent of total billed charges,90% of total billed charges,26.66,90,
VANCOMYCIN IVPB 2750 MG,,,636,RC,J3370,HCPCS,outpatient,4,UN,264,158.40,,158.4,60,,126.72,percent of total billed charges,60% of total billed charges,126.72,48,,101.376,percent of total billed charges,48% of total billed charges,3.05,100,,,fee schedule,100% of bcbs custom fee schedule,3.05,100,,,fee schedule,100% of bcbs custom fee schedule,3.39,111,,,fee schedule,111% of bcbs custom fee schedule,132,50,,105.6,percent of total billed charges,50% of total billed charges,184.8,70,,147.84,percent of total billed charges,70% of total billed charges,127.99,48.48,,102.392,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,127.99,48.48,,102.392,percent of total billed charges,48.48% of total billed charges,184.8,70,,147.84,percent of total billed charges,70% of total billed charges,184.8,70,,147.84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,127.99,48.48,,102.392,percent of total billed charges,48.48% of total billed charges,237.6,90,,190.08,percent of total billed charges,90% of total billed charges,48.48,237.6,
PREPARATION H OINT,,,259,RC,,,outpatient,,,31,18.60,,18.6,60,,14.88,percent of total billed charges,60% of total billed charges,14.88,48,,11.904,percent of total billed charges,48% of total billed charges,15.5,50,,12.4,percent of total billed charges,50% of total billed charges,15.5,50,,12.4,percent of total billed charges,50% of total billed charges,15.5,50,,12.4,percent of total billed charges,50% of total billed charges,15.5,50,,12.4,percent of total billed charges,50% of total billed charges,21.7,70,,17.36,percent of total billed charges,70% of total billed charges,15.03,48.48,,12.024,percent of total billed charges,48.48% of total billed charges,15.03,48.48,,12.024,percent of total billed charges,48.48% of total billed charges,15.03,48.48,,12.024,percent of total billed charges,48.48% of total billed charges,21.7,70,,17.36,percent of total billed charges,70% of total billed charges,21.7,70,,17.36,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,15.03,48.48,,12.024,percent of total billed charges,48.48% of total billed charges,27.9,90,,22.32,percent of total billed charges,90% of total billed charges,15.03,90,
MIDODRINE 5MG TAB,,,259,RC,,,outpatient,,,18,10.80,,10.8,60,,8.64,percent of total billed charges,60% of total billed charges,8.64,48,,6.912,percent of total billed charges,48% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,12.6,70,,10.08,percent of total billed charges,70% of total billed charges,8.73,48.48,,6.984,percent of total billed charges,48.48% of total billed charges,8.73,48.48,,6.984,percent of total billed charges,48.48% of total billed charges,8.73,48.48,,6.984,percent of total billed charges,48.48% of total billed charges,12.6,70,,10.08,percent of total billed charges,70% of total billed charges,12.6,70,,10.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,8.73,48.48,,6.984,percent of total billed charges,48.48% of total billed charges,16.2,90,,12.96,percent of total billed charges,90% of total billed charges,8.73,90,
Venofer 20mg/ml,,,250,RC,,,outpatient,,,528,316.80,,316.8,60,,253.44,percent of total billed charges,60% of total billed charges,253.44,48,,202.752,percent of total billed charges,48% of total billed charges,264,50,,211.2,percent of total billed charges,50% of total billed charges,264,50,,211.2,percent of total billed charges,50% of total billed charges,264,50,,211.2,percent of total billed charges,50% of total billed charges,264,50,,211.2,percent of total billed charges,50% of total billed charges,369.6,70,,295.68,percent of total billed charges,70% of total billed charges,255.97,48.48,,204.776,percent of total billed charges,48.48% of total billed charges,255.97,48.48,,204.776,percent of total billed charges,48.48% of total billed charges,255.97,48.48,,204.776,percent of total billed charges,48.48% of total billed charges,369.6,70,,295.68,percent of total billed charges,70% of total billed charges,369.6,70,,295.68,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,255.97,48.48,,204.776,percent of total billed charges,48.48% of total billed charges,475.2,90,,380.16,percent of total billed charges,90% of total billed charges,48.48,475.2,
VANCOMYCIN IVPB 2 GM PREMIX,,,636,RC,J3370,HCPCS,outpatient,4,UN,135,81.00,,81,60,,64.8,percent of total billed charges,60% of total billed charges,64.8,48,,51.84,percent of total billed charges,48% of total billed charges,3.05,100,,,fee schedule,100% of bcbs custom fee schedule,3.05,100,,,fee schedule,100% of bcbs custom fee schedule,3.39,111,,,fee schedule,111% of bcbs custom fee schedule,67.5,50,,54,percent of total billed charges,50% of total billed charges,94.5,70,,75.6,percent of total billed charges,70% of total billed charges,65.45,48.48,,52.36,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,65.45,48.48,,52.36,percent of total billed charges,48.48% of total billed charges,94.5,70,,75.6,percent of total billed charges,70% of total billed charges,94.5,70,,75.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,65.45,48.48,,52.36,percent of total billed charges,48.48% of total billed charges,121.5,90,,97.2,percent of total billed charges,90% of total billed charges,48.48,121.5,
CEREBYX INJ 1000 MG/20 ML,,,636,RC,Q2009,HCPCS,outpatient,20,UN,961,576.60,,576.6,60,,461.28,percent of total billed charges,60% of total billed charges,461.28,48,,369.024,percent of total billed charges,48% of total billed charges,5.47,100,,,fee schedule,100% of bcbs custom fee schedule,5.47,100,,,fee schedule,100% of bcbs custom fee schedule,6.07,111,,,fee schedule,111% of bcbs custom fee schedule,480.5,50,,384.4,percent of total billed charges,50% of total billed charges,672.7,70,,538.16,percent of total billed charges,70% of total billed charges,465.89,48.48,,372.712,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,465.89,48.48,,372.712,percent of total billed charges,48.48% of total billed charges,672.7,70,,538.16,percent of total billed charges,70% of total billed charges,672.7,70,,538.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,465.89,48.48,,372.712,percent of total billed charges,48.48% of total billed charges,864.9,90,,691.92,percent of total billed charges,90% of total billed charges,48.48,864.9,
DALBAVANCIN INJ 1500 (ONE DOSE),,,636,RC,J0875,HCPCS,outpatient,300,UN,11724,7034.40,,7034.4,60,,5627.52,percent of total billed charges,60% of total billed charges,5627.52,48,,4502.016,percent of total billed charges,48% of total billed charges,16.93,100,,,fee schedule,100% of bcbs custom fee schedule,16.93,100,,,fee schedule,100% of bcbs custom fee schedule,18.79,111,,,fee schedule,111% of bcbs custom fee schedule,5862,50,,4689.6,percent of total billed charges,50% of total billed charges,8206.8,70,,6565.44,percent of total billed charges,70% of total billed charges,5683.8,48.48,,4547.04,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,5683.8,48.48,,4547.04,percent of total billed charges,48.48% of total billed charges,8206.8,70,,6565.44,percent of total billed charges,70% of total billed charges,8206.8,70,,6565.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,5683.8,48.48,,4547.04,percent of total billed charges,48.48% of total billed charges,10551.6,90,,8441.28,percent of total billed charges,90% of total billed charges,48.48,10551.6,
MEROPENEM INJ 1 GM,,,636,RC,,,outpatient,,,53,31.80,,31.8,60,,25.44,percent of total billed charges,60% of total billed charges,25.44,48,,20.352,percent of total billed charges,48% of total billed charges,26.5,50,,21.2,percent of total billed charges,50% of total billed charges,26.5,50,,21.2,percent of total billed charges,50% of total billed charges,26.5,50,,21.2,percent of total billed charges,50% of total billed charges,26.5,50,,21.2,percent of total billed charges,50% of total billed charges,37.1,70,,29.68,percent of total billed charges,70% of total billed charges,25.69,48.48,,20.552,percent of total billed charges,48.48% of total billed charges,25.69,48.48,,20.552,percent of total billed charges,48.48% of total billed charges,25.69,48.48,,20.552,percent of total billed charges,48.48% of total billed charges,37.1,70,,29.68,percent of total billed charges,70% of total billed charges,37.1,70,,29.68,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,25.69,48.48,,20.552,percent of total billed charges,48.48% of total billed charges,47.7,90,,38.16,percent of total billed charges,90% of total billed charges,25.69,90,
LIDOCAINE INJ 1% (5 ML),,,250,RC,J3490,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
INFLUENZA VACC - HIGH DOSE,43601732,CDM,636,RC,90662,HCPCS,outpatient,1,UN,90,54.00,,54,60,,43.2,percent of total billed charges,60% of total billed charges,43.2,48,,34.56,percent of total billed charges,48% of total billed charges,60.98,100,,,fee schedule,100% of bcbs custom fee schedule,60.98,100,,,fee schedule,100% of bcbs custom fee schedule,67.69,111,,,fee schedule,111% of bcbs custom fee schedule,45,50,,36,percent of total billed charges,50% of total billed charges,63,70,,50.4,percent of total billed charges,70% of total billed charges,43.63,48.48,,34.904,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,43.63,48.48,,34.904,percent of total billed charges,48.48% of total billed charges,63,70,,50.4,percent of total billed charges,70% of total billed charges,63,70,,50.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,43.63,48.48,,34.904,percent of total billed charges,48.48% of total billed charges,81,90,,64.8,percent of total billed charges,90% of total billed charges,43.63,90,
PIPERACILLIN/ TAZO 4.5 GM,,,636,RC,J2543,HCPCS,outpatient,4,UN,111,66.60,,66.6,60,,53.28,percent of total billed charges,60% of total billed charges,53.28,48,,42.624,percent of total billed charges,48% of total billed charges,1.82,100,,,fee schedule,100% of bcbs custom fee schedule,1.82,100,,,fee schedule,100% of bcbs custom fee schedule,2.02,111,,,fee schedule,111% of bcbs custom fee schedule,55.5,50,,44.4,percent of total billed charges,50% of total billed charges,77.7,70,,62.16,percent of total billed charges,70% of total billed charges,53.81,48.48,,43.048,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,53.81,48.48,,43.048,percent of total billed charges,48.48% of total billed charges,77.7,70,,62.16,percent of total billed charges,70% of total billed charges,77.7,70,,62.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,53.81,48.48,,43.048,percent of total billed charges,48.48% of total billed charges,99.9,90,,79.92,percent of total billed charges,90% of total billed charges,48.48,99.9,
CENTRUM LIQUID 8 OZ,,,257,RC,,,outpatient,,,33,19.80,,19.8,60,,15.84,percent of total billed charges,60% of total billed charges,15.84,48,,12.672,percent of total billed charges,48% of total billed charges,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,23.1,70,,18.48,percent of total billed charges,70% of total billed charges,16,48.48,,12.8,percent of total billed charges,48.48% of total billed charges,16,48.48,,12.8,percent of total billed charges,48.48% of total billed charges,16,48.48,,12.8,percent of total billed charges,48.48% of total billed charges,23.1,70,,18.48,percent of total billed charges,70% of total billed charges,23.1,70,,18.48,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,16,48.48,,12.8,percent of total billed charges,48.48% of total billed charges,29.7,90,,23.76,percent of total billed charges,90% of total billed charges,16,90,
NOC^ RAPAFLO CAP 8 MG,,,250,RC,J8499,HCPCS,outpatient,1,UN,36,21.60,,21.6,60,,17.28,percent of total billed charges,60% of total billed charges,17.28,48,,13.824,percent of total billed charges,48% of total billed charges,18,50,,14.4,percent of total billed charges,50% of total billed charges,18,50,,14.4,percent of total billed charges,50% of total billed charges,18,50,,14.4,percent of total billed charges,50% of total billed charges,18,50,,14.4,percent of total billed charges,50% of total billed charges,25.2,70,,20.16,percent of total billed charges,70% of total billed charges,17.45,48.48,,13.96,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,17.45,48.48,,13.96,percent of total billed charges,48.48% of total billed charges,25.2,70,,20.16,percent of total billed charges,70% of total billed charges,25.2,70,,20.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,17.45,48.48,,13.96,percent of total billed charges,48.48% of total billed charges,32.4,90,,25.92,percent of total billed charges,90% of total billed charges,17.45,90,
CEFOXITIN 1GM IVPB,,,636,RC,,,outpatient,,,48,28.80,,28.8,60,,23.04,percent of total billed charges,60% of total billed charges,23.04,48,,18.432,percent of total billed charges,48% of total billed charges,24,50,,19.2,percent of total billed charges,50% of total billed charges,24,50,,19.2,percent of total billed charges,50% of total billed charges,24,50,,19.2,percent of total billed charges,50% of total billed charges,24,50,,19.2,percent of total billed charges,50% of total billed charges,33.6,70,,26.88,percent of total billed charges,70% of total billed charges,23.27,48.48,,18.616,percent of total billed charges,48.48% of total billed charges,23.27,48.48,,18.616,percent of total billed charges,48.48% of total billed charges,23.27,48.48,,18.616,percent of total billed charges,48.48% of total billed charges,33.6,70,,26.88,percent of total billed charges,70% of total billed charges,33.6,70,,26.88,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,23.27,48.48,,18.616,percent of total billed charges,48.48% of total billed charges,43.2,90,,34.56,percent of total billed charges,90% of total billed charges,23.27,90,
RISPERDAL CONSTA,,,636,RC,J2794,HCPCS,outpatient,50,UN,1279,767.40,,767.4,60,,613.92,percent of total billed charges,60% of total billed charges,613.92,48,,491.136,percent of total billed charges,48% of total billed charges,11.58,100,,,fee schedule,100% of bcbs custom fee schedule,11.58,100,,,fee schedule,100% of bcbs custom fee schedule,12.85,111,,,fee schedule,111% of bcbs custom fee schedule,639.5,50,,511.6,percent of total billed charges,50% of total billed charges,895.3,70,,716.24,percent of total billed charges,70% of total billed charges,620.06,48.48,,496.048,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,620.06,48.48,,496.048,percent of total billed charges,48.48% of total billed charges,895.3,70,,716.24,percent of total billed charges,70% of total billed charges,895.3,70,,716.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,620.06,48.48,,496.048,percent of total billed charges,48.48% of total billed charges,1151.1,90,,920.88,percent of total billed charges,90% of total billed charges,48.48,1151.1,
NOC^ DDAVP NASAL SPRAY,,,250,RC,J3490,HCPCS,outpatient,1,UN,1325,795.00,,795,60,,636,percent of total billed charges,60% of total billed charges,636,48,,508.8,percent of total billed charges,48% of total billed charges,662.5,50,,530,percent of total billed charges,50% of total billed charges,662.5,50,,530,percent of total billed charges,50% of total billed charges,662.5,50,,530,percent of total billed charges,50% of total billed charges,662.5,50,,530,percent of total billed charges,50% of total billed charges,927.5,70,,742,percent of total billed charges,70% of total billed charges,642.36,48.48,,513.888,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,642.36,48.48,,513.888,percent of total billed charges,48.48% of total billed charges,927.5,70,,742,percent of total billed charges,70% of total billed charges,927.5,70,,742,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,642.36,48.48,,513.888,percent of total billed charges,48.48% of total billed charges,1192.5,90,,954,percent of total billed charges,90% of total billed charges,48.48,1192.5,
DEPLIN CAP 15 MG,,,259,RC,,,outpatient,,,29,17.40,,17.4,60,,13.92,percent of total billed charges,60% of total billed charges,13.92,48,,11.136,percent of total billed charges,48% of total billed charges,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,20.3,70,,16.24,percent of total billed charges,70% of total billed charges,14.06,48.48,,11.248,percent of total billed charges,48.48% of total billed charges,14.06,48.48,,11.248,percent of total billed charges,48.48% of total billed charges,14.06,48.48,,11.248,percent of total billed charges,48.48% of total billed charges,20.3,70,,16.24,percent of total billed charges,70% of total billed charges,20.3,70,,16.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,14.06,48.48,,11.248,percent of total billed charges,48.48% of total billed charges,26.1,90,,20.88,percent of total billed charges,90% of total billed charges,14.06,90,
KETAMINE 50MG/ML INJ,,,636,RC,J3490,HCPCS,outpatient,1,UN,56,33.60,,33.6,60,,26.88,percent of total billed charges,60% of total billed charges,26.88,48,,21.504,percent of total billed charges,48% of total billed charges,28,50,,22.4,percent of total billed charges,50% of total billed charges,28,50,,22.4,percent of total billed charges,50% of total billed charges,28,50,,22.4,percent of total billed charges,50% of total billed charges,28,50,,22.4,percent of total billed charges,50% of total billed charges,39.2,70,,31.36,percent of total billed charges,70% of total billed charges,27.15,48.48,,21.72,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,27.15,48.48,,21.72,percent of total billed charges,48.48% of total billed charges,39.2,70,,31.36,percent of total billed charges,70% of total billed charges,39.2,70,,31.36,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,27.15,48.48,,21.72,percent of total billed charges,48.48% of total billed charges,50.4,90,,40.32,percent of total billed charges,90% of total billed charges,27.15,90,
DULERA INH 100/5 MCG 60 UNTI,,,250,RC,,,outpatient,,,1012,607.20,,607.2,60,,485.76,percent of total billed charges,60% of total billed charges,485.76,48,,388.608,percent of total billed charges,48% of total billed charges,506,50,,404.8,percent of total billed charges,50% of total billed charges,506,50,,404.8,percent of total billed charges,50% of total billed charges,506,50,,404.8,percent of total billed charges,50% of total billed charges,506,50,,404.8,percent of total billed charges,50% of total billed charges,708.4,70,,566.72,percent of total billed charges,70% of total billed charges,490.62,48.48,,392.496,percent of total billed charges,48.48% of total billed charges,490.62,48.48,,392.496,percent of total billed charges,48.48% of total billed charges,490.62,48.48,,392.496,percent of total billed charges,48.48% of total billed charges,708.4,70,,566.72,percent of total billed charges,70% of total billed charges,708.4,70,,566.72,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,490.62,48.48,,392.496,percent of total billed charges,48.48% of total billed charges,910.8,90,,728.64,percent of total billed charges,90% of total billed charges,48.48,910.8,
NAMENDA XR 7 MG CAP,,,250,RC,,,outpatient,,,62,37.20,,37.2,60,,29.76,percent of total billed charges,60% of total billed charges,29.76,48,,23.808,percent of total billed charges,48% of total billed charges,31,50,,24.8,percent of total billed charges,50% of total billed charges,31,50,,24.8,percent of total billed charges,50% of total billed charges,31,50,,24.8,percent of total billed charges,50% of total billed charges,31,50,,24.8,percent of total billed charges,50% of total billed charges,43.4,70,,34.72,percent of total billed charges,70% of total billed charges,30.06,48.48,,24.048,percent of total billed charges,48.48% of total billed charges,30.06,48.48,,24.048,percent of total billed charges,48.48% of total billed charges,30.06,48.48,,24.048,percent of total billed charges,48.48% of total billed charges,43.4,70,,34.72,percent of total billed charges,70% of total billed charges,43.4,70,,34.72,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,30.06,48.48,,24.048,percent of total billed charges,48.48% of total billed charges,55.8,90,,44.64,percent of total billed charges,90% of total billed charges,30.06,90,
MEROPENEM PRMX 1G,,,636,RC,J2184,HCPCS,outpatient,10,UN,144,86.40,,86.4,60,,69.12,percent of total billed charges,60% of total billed charges,69.12,48,,55.296,percent of total billed charges,48% of total billed charges,72,50,,57.6,percent of total billed charges,50% of total billed charges,72,50,,57.6,percent of total billed charges,50% of total billed charges,72,50,,57.6,percent of total billed charges,50% of total billed charges,72,50,,57.6,percent of total billed charges,50% of total billed charges,100.8,70,,80.64,percent of total billed charges,70% of total billed charges,69.81,48.48,,55.848,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,69.81,48.48,,55.848,percent of total billed charges,48.48% of total billed charges,100.8,70,,80.64,percent of total billed charges,70% of total billed charges,100.8,70,,80.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,69.81,48.48,,55.848,percent of total billed charges,48.48% of total billed charges,129.6,90,,103.68,percent of total billed charges,90% of total billed charges,48.48,129.6,
HIB Vaccine (ACTHIB),43601406,CDM,250,RC,90648,HCPCS,outpatient,1,UN,45,27.00,,27,60,,21.6,percent of total billed charges,60% of total billed charges,21.6,48,,17.28,percent of total billed charges,48% of total billed charges,12.57,100,,,fee schedule,100% of bcbs custom fee schedule,12.57,100,,,fee schedule,100% of bcbs custom fee schedule,13.95,111,,,fee schedule,111% of bcbs custom fee schedule,22.5,50,,18,percent of total billed charges,50% of total billed charges,31.5,70,,25.2,percent of total billed charges,70% of total billed charges,21.82,48.48,,17.456,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,21.82,48.48,,17.456,percent of total billed charges,48.48% of total billed charges,31.5,70,,25.2,percent of total billed charges,70% of total billed charges,31.5,70,,25.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,21.82,48.48,,17.456,percent of total billed charges,48.48% of total billed charges,40.5,90,,32.4,percent of total billed charges,90% of total billed charges,21.82,90,
MEROPENUM PRMX 500 MG,,,636,RC,J2184,HCPCS,outpatient,5,UN,99,59.40,,59.4,60,,47.52,percent of total billed charges,60% of total billed charges,47.52,48,,38.016,percent of total billed charges,48% of total billed charges,49.5,50,,39.6,percent of total billed charges,50% of total billed charges,49.5,50,,39.6,percent of total billed charges,50% of total billed charges,49.5,50,,39.6,percent of total billed charges,50% of total billed charges,49.5,50,,39.6,percent of total billed charges,50% of total billed charges,69.3,70,,55.44,percent of total billed charges,70% of total billed charges,48,48.48,,38.4,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,48,48.48,,38.4,percent of total billed charges,48.48% of total billed charges,69.3,70,,55.44,percent of total billed charges,70% of total billed charges,69.3,70,,55.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,48,48.48,,38.4,percent of total billed charges,48.48% of total billed charges,89.1,90,,71.28,percent of total billed charges,90% of total billed charges,48,90,
ERAXIS INJ 100 MG,,,636,RC,,,outpatient,,,908,544.80,,544.8,60,,435.84,percent of total billed charges,60% of total billed charges,435.84,48,,348.672,percent of total billed charges,48% of total billed charges,454,50,,363.2,percent of total billed charges,50% of total billed charges,454,50,,363.2,percent of total billed charges,50% of total billed charges,454,50,,363.2,percent of total billed charges,50% of total billed charges,454,50,,363.2,percent of total billed charges,50% of total billed charges,635.6,70,,508.48,percent of total billed charges,70% of total billed charges,440.2,48.48,,352.16,percent of total billed charges,48.48% of total billed charges,440.2,48.48,,352.16,percent of total billed charges,48.48% of total billed charges,440.2,48.48,,352.16,percent of total billed charges,48.48% of total billed charges,635.6,70,,508.48,percent of total billed charges,70% of total billed charges,635.6,70,,508.48,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,440.2,48.48,,352.16,percent of total billed charges,48.48% of total billed charges,817.2,90,,653.76,percent of total billed charges,90% of total billed charges,48.48,817.2,
INVOKANA TAB 300 MG,,,250,RC,,,outpatient,,,87,52.20,,52.2,60,,41.76,percent of total billed charges,60% of total billed charges,41.76,48,,33.408,percent of total billed charges,48% of total billed charges,43.5,50,,34.8,percent of total billed charges,50% of total billed charges,43.5,50,,34.8,percent of total billed charges,50% of total billed charges,43.5,50,,34.8,percent of total billed charges,50% of total billed charges,43.5,50,,34.8,percent of total billed charges,50% of total billed charges,60.9,70,,48.72,percent of total billed charges,70% of total billed charges,42.18,48.48,,33.744,percent of total billed charges,48.48% of total billed charges,42.18,48.48,,33.744,percent of total billed charges,48.48% of total billed charges,42.18,48.48,,33.744,percent of total billed charges,48.48% of total billed charges,60.9,70,,48.72,percent of total billed charges,70% of total billed charges,60.9,70,,48.72,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,42.18,48.48,,33.744,percent of total billed charges,48.48% of total billed charges,78.3,90,,62.64,percent of total billed charges,90% of total billed charges,42.18,90,
KETOCONAZOLE SHAMPOO,,,250,RC,,,outpatient,,,121,72.60,,72.6,60,,58.08,percent of total billed charges,60% of total billed charges,58.08,48,,46.464,percent of total billed charges,48% of total billed charges,60.5,50,,48.4,percent of total billed charges,50% of total billed charges,60.5,50,,48.4,percent of total billed charges,50% of total billed charges,60.5,50,,48.4,percent of total billed charges,50% of total billed charges,60.5,50,,48.4,percent of total billed charges,50% of total billed charges,84.7,70,,67.76,percent of total billed charges,70% of total billed charges,58.66,48.48,,46.928,percent of total billed charges,48.48% of total billed charges,58.66,48.48,,46.928,percent of total billed charges,48.48% of total billed charges,58.66,48.48,,46.928,percent of total billed charges,48.48% of total billed charges,84.7,70,,67.76,percent of total billed charges,70% of total billed charges,84.7,70,,67.76,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,58.66,48.48,,46.928,percent of total billed charges,48.48% of total billed charges,108.9,90,,87.12,percent of total billed charges,90% of total billed charges,48.48,108.9,
CHLORTHALIDONE 25 MG,,,259,RC,,,outpatient,,,10,6.00,,6,60,,4.8,percent of total billed charges,60% of total billed charges,4.8,48,,3.84,percent of total billed charges,48% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,7,70,,5.6,percent of total billed charges,70% of total billed charges,4.85,48.48,,3.88,percent of total billed charges,48.48% of total billed charges,4.85,48.48,,3.88,percent of total billed charges,48.48% of total billed charges,4.85,48.48,,3.88,percent of total billed charges,48.48% of total billed charges,7,70,,5.6,percent of total billed charges,70% of total billed charges,7,70,,5.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,4.85,48.48,,3.88,percent of total billed charges,48.48% of total billed charges,9,90,,7.2,percent of total billed charges,90% of total billed charges,4.85,90,
CEFDINIR SUSP 250 MG (60 ML),,,259,RC,,,outpatient,,,398,238.80,,238.8,60,,191.04,percent of total billed charges,60% of total billed charges,191.04,48,,152.832,percent of total billed charges,48% of total billed charges,199,50,,159.2,percent of total billed charges,50% of total billed charges,199,50,,159.2,percent of total billed charges,50% of total billed charges,199,50,,159.2,percent of total billed charges,50% of total billed charges,199,50,,159.2,percent of total billed charges,50% of total billed charges,278.6,70,,222.88,percent of total billed charges,70% of total billed charges,192.95,48.48,,154.36,percent of total billed charges,48.48% of total billed charges,192.95,48.48,,154.36,percent of total billed charges,48.48% of total billed charges,192.95,48.48,,154.36,percent of total billed charges,48.48% of total billed charges,278.6,70,,222.88,percent of total billed charges,70% of total billed charges,278.6,70,,222.88,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,192.95,48.48,,154.36,percent of total billed charges,48.48% of total billed charges,358.2,90,,286.56,percent of total billed charges,90% of total billed charges,48.48,358.2,
HIBICLEANS 16 OZ,,,250,RC,,,outpatient,,,64,38.40,,38.4,60,,30.72,percent of total billed charges,60% of total billed charges,30.72,48,,24.576,percent of total billed charges,48% of total billed charges,32,50,,25.6,percent of total billed charges,50% of total billed charges,32,50,,25.6,percent of total billed charges,50% of total billed charges,32,50,,25.6,percent of total billed charges,50% of total billed charges,32,50,,25.6,percent of total billed charges,50% of total billed charges,44.8,70,,35.84,percent of total billed charges,70% of total billed charges,31.03,48.48,,24.824,percent of total billed charges,48.48% of total billed charges,31.03,48.48,,24.824,percent of total billed charges,48.48% of total billed charges,31.03,48.48,,24.824,percent of total billed charges,48.48% of total billed charges,44.8,70,,35.84,percent of total billed charges,70% of total billed charges,44.8,70,,35.84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,31.03,48.48,,24.824,percent of total billed charges,48.48% of total billed charges,57.6,90,,46.08,percent of total billed charges,90% of total billed charges,31.03,90,
AMPHOJEL,,,259,RC,,,outpatient,,,25,15.00,,15,60,,12,percent of total billed charges,60% of total billed charges,12,48,,9.6,percent of total billed charges,48% of total billed charges,12.5,50,,10,percent of total billed charges,50% of total billed charges,12.5,50,,10,percent of total billed charges,50% of total billed charges,12.5,50,,10,percent of total billed charges,50% of total billed charges,12.5,50,,10,percent of total billed charges,50% of total billed charges,17.5,70,,14,percent of total billed charges,70% of total billed charges,12.12,48.48,,9.696,percent of total billed charges,48.48% of total billed charges,12.12,48.48,,9.696,percent of total billed charges,48.48% of total billed charges,12.12,48.48,,9.696,percent of total billed charges,48.48% of total billed charges,17.5,70,,14,percent of total billed charges,70% of total billed charges,17.5,70,,14,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,12.12,48.48,,9.696,percent of total billed charges,48.48% of total billed charges,22.5,90,,18,percent of total billed charges,90% of total billed charges,12.12,90,
PERMETHRIN CRM 60 GM,,,259,RC,,,outpatient,,,495,297.00,,297,60,,237.6,percent of total billed charges,60% of total billed charges,237.6,48,,190.08,percent of total billed charges,48% of total billed charges,247.5,50,,198,percent of total billed charges,50% of total billed charges,247.5,50,,198,percent of total billed charges,50% of total billed charges,247.5,50,,198,percent of total billed charges,50% of total billed charges,247.5,50,,198,percent of total billed charges,50% of total billed charges,346.5,70,,277.2,percent of total billed charges,70% of total billed charges,239.98,48.48,,191.984,percent of total billed charges,48.48% of total billed charges,239.98,48.48,,191.984,percent of total billed charges,48.48% of total billed charges,239.98,48.48,,191.984,percent of total billed charges,48.48% of total billed charges,346.5,70,,277.2,percent of total billed charges,70% of total billed charges,346.5,70,,277.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,239.98,48.48,,191.984,percent of total billed charges,48.48% of total billed charges,445.5,90,,356.4,percent of total billed charges,90% of total billed charges,48.48,445.5,
NOC^ LUMIGAN OPTH 0.01%,,,250,RC,J3490,HCPCS,outpatient,1,UN,1043,625.80,,625.8,60,,500.64,percent of total billed charges,60% of total billed charges,500.64,48,,400.512,percent of total billed charges,48% of total billed charges,521.5,50,,417.2,percent of total billed charges,50% of total billed charges,521.5,50,,417.2,percent of total billed charges,50% of total billed charges,521.5,50,,417.2,percent of total billed charges,50% of total billed charges,521.5,50,,417.2,percent of total billed charges,50% of total billed charges,730.1,70,,584.08,percent of total billed charges,70% of total billed charges,505.65,48.48,,404.52,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,505.65,48.48,,404.52,percent of total billed charges,48.48% of total billed charges,730.1,70,,584.08,percent of total billed charges,70% of total billed charges,730.1,70,,584.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,505.65,48.48,,404.52,percent of total billed charges,48.48% of total billed charges,938.7,90,,750.96,percent of total billed charges,90% of total billed charges,48.48,938.7,
NOC^ COMBIGAN OPTH 0.2%,,,250,RC,J3490,HCPCS,outpatient,1,UN,934,560.40,,560.4,60,,448.32,percent of total billed charges,60% of total billed charges,448.32,48,,358.656,percent of total billed charges,48% of total billed charges,467,50,,373.6,percent of total billed charges,50% of total billed charges,467,50,,373.6,percent of total billed charges,50% of total billed charges,467,50,,373.6,percent of total billed charges,50% of total billed charges,467,50,,373.6,percent of total billed charges,50% of total billed charges,653.8,70,,523.04,percent of total billed charges,70% of total billed charges,452.8,48.48,,362.24,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,452.8,48.48,,362.24,percent of total billed charges,48.48% of total billed charges,653.8,70,,523.04,percent of total billed charges,70% of total billed charges,653.8,70,,523.04,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,452.8,48.48,,362.24,percent of total billed charges,48.48% of total billed charges,840.6,90,,672.48,percent of total billed charges,90% of total billed charges,48.48,840.6,
ENTRESTO TAB [24MG/26MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,47,28.20,,28.2,60,,22.56,percent of total billed charges,60% of total billed charges,22.56,48,,18.048,percent of total billed charges,48% of total billed charges,23.5,50,,18.8,percent of total billed charges,50% of total billed charges,23.5,50,,18.8,percent of total billed charges,50% of total billed charges,23.5,50,,18.8,percent of total billed charges,50% of total billed charges,23.5,50,,18.8,percent of total billed charges,50% of total billed charges,32.9,70,,26.32,percent of total billed charges,70% of total billed charges,22.79,48.48,,18.232,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,22.79,48.48,,18.232,percent of total billed charges,48.48% of total billed charges,32.9,70,,26.32,percent of total billed charges,70% of total billed charges,32.9,70,,26.32,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,22.79,48.48,,18.232,percent of total billed charges,48.48% of total billed charges,42.3,90,,33.84,percent of total billed charges,90% of total billed charges,22.79,90,
CATHFLO ACTIVASE 2 MG,,,636,RC,,,outpatient,,,735,441.00,,441,60,,352.8,percent of total billed charges,60% of total billed charges,352.8,48,,282.24,percent of total billed charges,48% of total billed charges,367.5,50,,294,percent of total billed charges,50% of total billed charges,367.5,50,,294,percent of total billed charges,50% of total billed charges,367.5,50,,294,percent of total billed charges,50% of total billed charges,367.5,50,,294,percent of total billed charges,50% of total billed charges,514.5,70,,411.6,percent of total billed charges,70% of total billed charges,356.33,48.48,,285.064,percent of total billed charges,48.48% of total billed charges,356.33,48.48,,285.064,percent of total billed charges,48.48% of total billed charges,356.33,48.48,,285.064,percent of total billed charges,48.48% of total billed charges,514.5,70,,411.6,percent of total billed charges,70% of total billed charges,514.5,70,,411.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,356.33,48.48,,285.064,percent of total billed charges,48.48% of total billed charges,661.5,90,,529.2,percent of total billed charges,90% of total billed charges,48.48,661.5,
OXYCONTIN CR 15 MG,,,259,RC,,,outpatient,,,33,19.80,,19.8,60,,15.84,percent of total billed charges,60% of total billed charges,15.84,48,,12.672,percent of total billed charges,48% of total billed charges,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,23.1,70,,18.48,percent of total billed charges,70% of total billed charges,16,48.48,,12.8,percent of total billed charges,48.48% of total billed charges,16,48.48,,12.8,percent of total billed charges,48.48% of total billed charges,16,48.48,,12.8,percent of total billed charges,48.48% of total billed charges,23.1,70,,18.48,percent of total billed charges,70% of total billed charges,23.1,70,,18.48,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,16,48.48,,12.8,percent of total billed charges,48.48% of total billed charges,29.7,90,,23.76,percent of total billed charges,90% of total billed charges,16,90,
BENICAR TAB 40 MG,,,259,RC,,,outpatient,,,35,21.00,,21,60,,16.8,percent of total billed charges,60% of total billed charges,16.8,48,,13.44,percent of total billed charges,48% of total billed charges,17.5,50,,14,percent of total billed charges,50% of total billed charges,17.5,50,,14,percent of total billed charges,50% of total billed charges,17.5,50,,14,percent of total billed charges,50% of total billed charges,17.5,50,,14,percent of total billed charges,50% of total billed charges,24.5,70,,19.6,percent of total billed charges,70% of total billed charges,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,24.5,70,,19.6,percent of total billed charges,70% of total billed charges,24.5,70,,19.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,31.5,90,,25.2,percent of total billed charges,90% of total billed charges,16.97,90,
TINACTIN CRM,,,259,RC,,,outpatient,,,38,22.80,,22.8,60,,18.24,percent of total billed charges,60% of total billed charges,18.24,48,,14.592,percent of total billed charges,48% of total billed charges,19,50,,15.2,percent of total billed charges,50% of total billed charges,19,50,,15.2,percent of total billed charges,50% of total billed charges,19,50,,15.2,percent of total billed charges,50% of total billed charges,19,50,,15.2,percent of total billed charges,50% of total billed charges,26.6,70,,21.28,percent of total billed charges,70% of total billed charges,18.42,48.48,,14.736,percent of total billed charges,48.48% of total billed charges,18.42,48.48,,14.736,percent of total billed charges,48.48% of total billed charges,18.42,48.48,,14.736,percent of total billed charges,48.48% of total billed charges,26.6,70,,21.28,percent of total billed charges,70% of total billed charges,26.6,70,,21.28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,18.42,48.48,,14.736,percent of total billed charges,48.48% of total billed charges,34.2,90,,27.36,percent of total billed charges,90% of total billed charges,18.42,90,
CHOLESTYRAMIN/AQUAPHOR CRM,,,259,RC,,,outpatient,,,120,72.00,,72,60,,57.6,percent of total billed charges,60% of total billed charges,57.6,48,,46.08,percent of total billed charges,48% of total billed charges,60,50,,48,percent of total billed charges,50% of total billed charges,60,50,,48,percent of total billed charges,50% of total billed charges,60,50,,48,percent of total billed charges,50% of total billed charges,60,50,,48,percent of total billed charges,50% of total billed charges,84,70,,67.2,percent of total billed charges,70% of total billed charges,58.18,48.48,,46.544,percent of total billed charges,48.48% of total billed charges,58.18,48.48,,46.544,percent of total billed charges,48.48% of total billed charges,58.18,48.48,,46.544,percent of total billed charges,48.48% of total billed charges,84,70,,67.2,percent of total billed charges,70% of total billed charges,84,70,,67.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,58.18,48.48,,46.544,percent of total billed charges,48.48% of total billed charges,108,90,,86.4,percent of total billed charges,90% of total billed charges,48.48,108,
NEUDEXTA CAP 10/20 MG,,,259,RC,,,outpatient,,,107,64.20,,64.2,60,,51.36,percent of total billed charges,60% of total billed charges,51.36,48,,41.088,percent of total billed charges,48% of total billed charges,53.5,50,,42.8,percent of total billed charges,50% of total billed charges,53.5,50,,42.8,percent of total billed charges,50% of total billed charges,53.5,50,,42.8,percent of total billed charges,50% of total billed charges,53.5,50,,42.8,percent of total billed charges,50% of total billed charges,74.9,70,,59.92,percent of total billed charges,70% of total billed charges,51.87,48.48,,41.496,percent of total billed charges,48.48% of total billed charges,51.87,48.48,,41.496,percent of total billed charges,48.48% of total billed charges,51.87,48.48,,41.496,percent of total billed charges,48.48% of total billed charges,74.9,70,,59.92,percent of total billed charges,70% of total billed charges,74.9,70,,59.92,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,51.87,48.48,,41.496,percent of total billed charges,48.48% of total billed charges,96.3,90,,77.04,percent of total billed charges,90% of total billed charges,48.48,96.3,
KLOR-CON PKT 20 MEQ,,,259,RC,,,outpatient,,,43,25.80,,25.8,60,,20.64,percent of total billed charges,60% of total billed charges,20.64,48,,16.512,percent of total billed charges,48% of total billed charges,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,30.1,70,,24.08,percent of total billed charges,70% of total billed charges,20.85,48.48,,16.68,percent of total billed charges,48.48% of total billed charges,20.85,48.48,,16.68,percent of total billed charges,48.48% of total billed charges,20.85,48.48,,16.68,percent of total billed charges,48.48% of total billed charges,30.1,70,,24.08,percent of total billed charges,70% of total billed charges,30.1,70,,24.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,20.85,48.48,,16.68,percent of total billed charges,48.48% of total billed charges,38.7,90,,30.96,percent of total billed charges,90% of total billed charges,20.85,90,
DAKINS SOL 0.125%,,,259,RC,,,outpatient,,,59,35.40,,35.4,60,,28.32,percent of total billed charges,60% of total billed charges,28.32,48,,22.656,percent of total billed charges,48% of total billed charges,29.5,50,,23.6,percent of total billed charges,50% of total billed charges,29.5,50,,23.6,percent of total billed charges,50% of total billed charges,29.5,50,,23.6,percent of total billed charges,50% of total billed charges,29.5,50,,23.6,percent of total billed charges,50% of total billed charges,41.3,70,,33.04,percent of total billed charges,70% of total billed charges,28.6,48.48,,22.88,percent of total billed charges,48.48% of total billed charges,28.6,48.48,,22.88,percent of total billed charges,48.48% of total billed charges,28.6,48.48,,22.88,percent of total billed charges,48.48% of total billed charges,41.3,70,,33.04,percent of total billed charges,70% of total billed charges,41.3,70,,33.04,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,28.6,48.48,,22.88,percent of total billed charges,48.48% of total billed charges,53.1,90,,42.48,percent of total billed charges,90% of total billed charges,28.6,90,
REXULTI TAB 2 MG,,,259,RC,,,outpatient,,,200,120.00,,120,60,,96,percent of total billed charges,60% of total billed charges,96,48,,76.8,percent of total billed charges,48% of total billed charges,100,50,,80,percent of total billed charges,50% of total billed charges,100,50,,80,percent of total billed charges,50% of total billed charges,100,50,,80,percent of total billed charges,50% of total billed charges,100,50,,80,percent of total billed charges,50% of total billed charges,140,70,,112,percent of total billed charges,70% of total billed charges,96.96,48.48,,77.568,percent of total billed charges,48.48% of total billed charges,96.96,48.48,,77.568,percent of total billed charges,48.48% of total billed charges,96.96,48.48,,77.568,percent of total billed charges,48.48% of total billed charges,140,70,,112,percent of total billed charges,70% of total billed charges,140,70,,112,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,96.96,48.48,,77.568,percent of total billed charges,48.48% of total billed charges,180,90,,144,percent of total billed charges,90% of total billed charges,48.48,180,
SUMATRIPTAN TAB 50 MG,,,259,RC,,,outpatient,,,101,60.60,,60.6,60,,48.48,percent of total billed charges,60% of total billed charges,48.48,48,,38.784,percent of total billed charges,48% of total billed charges,50.5,50,,40.4,percent of total billed charges,50% of total billed charges,50.5,50,,40.4,percent of total billed charges,50% of total billed charges,50.5,50,,40.4,percent of total billed charges,50% of total billed charges,50.5,50,,40.4,percent of total billed charges,50% of total billed charges,70.7,70,,56.56,percent of total billed charges,70% of total billed charges,48.96,48.48,,39.168,percent of total billed charges,48.48% of total billed charges,48.96,48.48,,39.168,percent of total billed charges,48.48% of total billed charges,48.96,48.48,,39.168,percent of total billed charges,48.48% of total billed charges,70.7,70,,56.56,percent of total billed charges,70% of total billed charges,70.7,70,,56.56,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,48.96,48.48,,39.168,percent of total billed charges,48.48% of total billed charges,90.9,90,,72.72,percent of total billed charges,90% of total billed charges,48.48,90.9,
AMIODARONE 150 MG/100 ML PRMX,,,636,RC,J0283,HCPCS,outpatient,,,167,100.20,,100.2,60,,80.16,percent of total billed charges,60% of total billed charges,80.16,48,,64.128,percent of total billed charges,48% of total billed charges,83.5,50,,66.8,percent of total billed charges,50% of total billed charges,83.5,50,,66.8,percent of total billed charges,50% of total billed charges,83.5,50,,66.8,percent of total billed charges,50% of total billed charges,83.5,50,,66.8,percent of total billed charges,50% of total billed charges,116.9,70,,93.52,percent of total billed charges,70% of total billed charges,80.96,48.48,,64.768,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,80.96,48.48,,64.768,percent of total billed charges,48.48% of total billed charges,116.9,70,,93.52,percent of total billed charges,70% of total billed charges,116.9,70,,93.52,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,80.96,48.48,,64.768,percent of total billed charges,48.48% of total billed charges,150.3,90,,120.24,percent of total billed charges,90% of total billed charges,48.48,150.3,
AMIODARONE 360 MG/200 ML PRMX,,,636,RC,J0283,HCPCS,outpatient,,,222,133.20,,133.2,60,,106.56,percent of total billed charges,60% of total billed charges,106.56,48,,85.248,percent of total billed charges,48% of total billed charges,111,50,,88.8,percent of total billed charges,50% of total billed charges,111,50,,88.8,percent of total billed charges,50% of total billed charges,111,50,,88.8,percent of total billed charges,50% of total billed charges,111,50,,88.8,percent of total billed charges,50% of total billed charges,155.4,70,,124.32,percent of total billed charges,70% of total billed charges,107.63,48.48,,86.104,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,107.63,48.48,,86.104,percent of total billed charges,48.48% of total billed charges,155.4,70,,124.32,percent of total billed charges,70% of total billed charges,155.4,70,,124.32,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,107.63,48.48,,86.104,percent of total billed charges,48.48% of total billed charges,199.8,90,,159.84,percent of total billed charges,90% of total billed charges,48.48,199.8,
AQUASOL (VIT A) INJ 2 ML,,,250,RC,,,outpatient,,,576,345.60,,345.6,60,,276.48,percent of total billed charges,60% of total billed charges,276.48,48,,221.184,percent of total billed charges,48% of total billed charges,288,50,,230.4,percent of total billed charges,50% of total billed charges,288,50,,230.4,percent of total billed charges,50% of total billed charges,288,50,,230.4,percent of total billed charges,50% of total billed charges,288,50,,230.4,percent of total billed charges,50% of total billed charges,403.2,70,,322.56,percent of total billed charges,70% of total billed charges,279.24,48.48,,223.392,percent of total billed charges,48.48% of total billed charges,279.24,48.48,,223.392,percent of total billed charges,48.48% of total billed charges,279.24,48.48,,223.392,percent of total billed charges,48.48% of total billed charges,403.2,70,,322.56,percent of total billed charges,70% of total billed charges,403.2,70,,322.56,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,279.24,48.48,,223.392,percent of total billed charges,48.48% of total billed charges,518.4,90,,414.72,percent of total billed charges,90% of total billed charges,48.48,518.4,
CEFAZOLIN *IVPB* 2GM PREMIX,,,636,RC,J0690,HCPCS,outpatient,,,71,42.60,,42.6,60,,34.08,percent of total billed charges,60% of total billed charges,34.08,48,,27.264,percent of total billed charges,48% of total billed charges,1.07,100,,,fee schedule,100% of bcbs custom fee schedule,1.07,100,,,fee schedule,100% of bcbs custom fee schedule,1.19,111,,,fee schedule,111% of bcbs custom fee schedule,35.5,50,,28.4,percent of total billed charges,50% of total billed charges,49.7,70,,39.76,percent of total billed charges,70% of total billed charges,34.42,48.48,,27.536,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,34.42,48.48,,27.536,percent of total billed charges,48.48% of total billed charges,49.7,70,,39.76,percent of total billed charges,70% of total billed charges,49.7,70,,39.76,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,34.42,48.48,,27.536,percent of total billed charges,48.48% of total billed charges,63.9,90,,51.12,percent of total billed charges,90% of total billed charges,34.42,90,
EPI-PEN 0.3MG,43601500,CDM,636,RC,J0171,HCPCS,outpatient,1,UN,1460,876.00,,876,60,,700.8,percent of total billed charges,60% of total billed charges,700.8,48,,560.64,percent of total billed charges,48% of total billed charges,0.97,100,,,fee schedule,100% of bcbs custom fee schedule,0.97,100,,,fee schedule,100% of bcbs custom fee schedule,1.08,111,,,fee schedule,111% of bcbs custom fee schedule,730,50,,584,percent of total billed charges,50% of total billed charges,1022,70,,817.6,percent of total billed charges,70% of total billed charges,707.81,48.48,,566.248,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,707.81,48.48,,566.248,percent of total billed charges,48.48% of total billed charges,1022,70,,817.6,percent of total billed charges,70% of total billed charges,1022,70,,817.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,707.81,48.48,,566.248,percent of total billed charges,48.48% of total billed charges,1314,90,,1051.2,percent of total billed charges,90% of total billed charges,48.48,1314,
XOLAIR INJ 150 MG,,,636,RC,,,outpatient,,,2790,1674.00,,1674,60,,1339.2,percent of total billed charges,60% of total billed charges,1339.2,48,,1071.36,percent of total billed charges,48% of total billed charges,1395,50,,1116,percent of total billed charges,50% of total billed charges,1395,50,,1116,percent of total billed charges,50% of total billed charges,1395,50,,1116,percent of total billed charges,50% of total billed charges,1395,50,,1116,percent of total billed charges,50% of total billed charges,1953,70,,1562.4,percent of total billed charges,70% of total billed charges,1352.59,48.48,,1082.072,percent of total billed charges,48.48% of total billed charges,1352.59,48.48,,1082.072,percent of total billed charges,48.48% of total billed charges,1352.59,48.48,,1082.072,percent of total billed charges,48.48% of total billed charges,1953,70,,1562.4,percent of total billed charges,70% of total billed charges,1953,70,,1562.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,1352.59,48.48,,1082.072,percent of total billed charges,48.48% of total billed charges,2511,90,,2008.8,percent of total billed charges,90% of total billed charges,48.48,2511,
DAPTACEL (TET/DIPTH/PERT),43601415,CDM,636,RC,90700,HCPCS,outpatient,,,83,49.80,,49.8,60,,39.84,percent of total billed charges,60% of total billed charges,39.84,48,,31.872,percent of total billed charges,48% of total billed charges,28.51,100,,,fee schedule,100% of bcbs custom fee schedule,28.51,100,,,fee schedule,100% of bcbs custom fee schedule,31.65,111,,,fee schedule,111% of bcbs custom fee schedule,41.5,50,,33.2,percent of total billed charges,50% of total billed charges,58.1,70,,46.48,percent of total billed charges,70% of total billed charges,40.24,48.48,,32.192,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,40.24,48.48,,32.192,percent of total billed charges,48.48% of total billed charges,58.1,70,,46.48,percent of total billed charges,70% of total billed charges,58.1,70,,46.48,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,40.24,48.48,,32.192,percent of total billed charges,48.48% of total billed charges,74.7,90,,59.76,percent of total billed charges,90% of total billed charges,40.24,90,
LATUDA TAB 40 MG,,,250,RC,,,outpatient,,,216,129.60,,129.6,60,,103.68,percent of total billed charges,60% of total billed charges,103.68,48,,82.944,percent of total billed charges,48% of total billed charges,108,50,,86.4,percent of total billed charges,50% of total billed charges,108,50,,86.4,percent of total billed charges,50% of total billed charges,108,50,,86.4,percent of total billed charges,50% of total billed charges,108,50,,86.4,percent of total billed charges,50% of total billed charges,151.2,70,,120.96,percent of total billed charges,70% of total billed charges,104.72,48.48,,83.776,percent of total billed charges,48.48% of total billed charges,104.72,48.48,,83.776,percent of total billed charges,48.48% of total billed charges,104.72,48.48,,83.776,percent of total billed charges,48.48% of total billed charges,151.2,70,,120.96,percent of total billed charges,70% of total billed charges,151.2,70,,120.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,104.72,48.48,,83.776,percent of total billed charges,48.48% of total billed charges,194.4,90,,155.52,percent of total billed charges,90% of total billed charges,48.48,194.4,
TRULICITY INJ PEN 1.5 MG,,,250,RC,,,outpatient,,,1014,608.40,,608.4,60,,486.72,percent of total billed charges,60% of total billed charges,486.72,48,,389.376,percent of total billed charges,48% of total billed charges,507,50,,405.6,percent of total billed charges,50% of total billed charges,507,50,,405.6,percent of total billed charges,50% of total billed charges,507,50,,405.6,percent of total billed charges,50% of total billed charges,507,50,,405.6,percent of total billed charges,50% of total billed charges,709.8,70,,567.84,percent of total billed charges,70% of total billed charges,491.59,48.48,,393.272,percent of total billed charges,48.48% of total billed charges,491.59,48.48,,393.272,percent of total billed charges,48.48% of total billed charges,491.59,48.48,,393.272,percent of total billed charges,48.48% of total billed charges,709.8,70,,567.84,percent of total billed charges,70% of total billed charges,709.8,70,,567.84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,491.59,48.48,,393.272,percent of total billed charges,48.48% of total billed charges,912.6,90,,730.08,percent of total billed charges,90% of total billed charges,48.48,912.6,
MORPH SULF O/CONC 20MG/ML [30 ML],,,250,RC,,,outpatient,,,90,54.00,,54,60,,43.2,percent of total billed charges,60% of total billed charges,43.2,48,,34.56,percent of total billed charges,48% of total billed charges,45,50,,36,percent of total billed charges,50% of total billed charges,45,50,,36,percent of total billed charges,50% of total billed charges,45,50,,36,percent of total billed charges,50% of total billed charges,45,50,,36,percent of total billed charges,50% of total billed charges,63,70,,50.4,percent of total billed charges,70% of total billed charges,43.63,48.48,,34.904,percent of total billed charges,48.48% of total billed charges,43.63,48.48,,34.904,percent of total billed charges,48.48% of total billed charges,43.63,48.48,,34.904,percent of total billed charges,48.48% of total billed charges,63,70,,50.4,percent of total billed charges,70% of total billed charges,63,70,,50.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,43.63,48.48,,34.904,percent of total billed charges,48.48% of total billed charges,81,90,,64.8,percent of total billed charges,90% of total billed charges,43.63,90,
DILAUDID INJ 4 MG/ML,,,250,RC,,,outpatient,,,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
CLEOCIN IVPB 600MG/NS50,,,636,RC,J0736,HCPCS,outpatient,,,60,36.00,,36,60,,28.8,percent of total billed charges,60% of total billed charges,28.8,48,,23.04,percent of total billed charges,48% of total billed charges,30,50,,24,percent of total billed charges,50% of total billed charges,30,50,,24,percent of total billed charges,50% of total billed charges,30,50,,24,percent of total billed charges,50% of total billed charges,30,50,,24,percent of total billed charges,50% of total billed charges,42,70,,33.6,percent of total billed charges,70% of total billed charges,29.09,48.48,,23.272,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,29.09,48.48,,23.272,percent of total billed charges,48.48% of total billed charges,42,70,,33.6,percent of total billed charges,70% of total billed charges,42,70,,33.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,29.09,48.48,,23.272,percent of total billed charges,48.48% of total billed charges,54,90,,43.2,percent of total billed charges,90% of total billed charges,29.09,90,
MYCAMINE 100 MG IV,,,636,RC,J2246,HCPCS,outpatient,100,UN,349,209.40,,209.4,60,,167.52,percent of total billed charges,60% of total billed charges,167.52,48,,134.016,percent of total billed charges,48% of total billed charges,174.5,50,,139.6,percent of total billed charges,50% of total billed charges,174.5,50,,139.6,percent of total billed charges,50% of total billed charges,174.5,50,,139.6,percent of total billed charges,50% of total billed charges,174.5,50,,139.6,percent of total billed charges,50% of total billed charges,244.3,70,,195.44,percent of total billed charges,70% of total billed charges,169.2,48.48,,135.36,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,169.2,48.48,,135.36,percent of total billed charges,48.48% of total billed charges,244.3,70,,195.44,percent of total billed charges,70% of total billed charges,244.3,70,,195.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,169.2,48.48,,135.36,percent of total billed charges,48.48% of total billed charges,314.1,90,,251.28,percent of total billed charges,90% of total billed charges,48.48,314.1,
CLINIMIX E 4.25/25,,,250,RC,,,outpatient,,,357,214.20,,214.2,60,,171.36,percent of total billed charges,60% of total billed charges,171.36,48,,137.088,percent of total billed charges,48% of total billed charges,178.5,50,,142.8,percent of total billed charges,50% of total billed charges,178.5,50,,142.8,percent of total billed charges,50% of total billed charges,178.5,50,,142.8,percent of total billed charges,50% of total billed charges,178.5,50,,142.8,percent of total billed charges,50% of total billed charges,249.9,70,,199.92,percent of total billed charges,70% of total billed charges,173.07,48.48,,138.456,percent of total billed charges,48.48% of total billed charges,173.07,48.48,,138.456,percent of total billed charges,48.48% of total billed charges,173.07,48.48,,138.456,percent of total billed charges,48.48% of total billed charges,249.9,70,,199.92,percent of total billed charges,70% of total billed charges,249.9,70,,199.92,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,173.07,48.48,,138.456,percent of total billed charges,48.48% of total billed charges,321.3,90,,257.04,percent of total billed charges,90% of total billed charges,48.48,321.3,
NAPHCON A OPTH DROPS,,,250,RC,,,outpatient,,,27,16.20,,16.2,60,,12.96,percent of total billed charges,60% of total billed charges,12.96,48,,10.368,percent of total billed charges,48% of total billed charges,13.5,50,,10.8,percent of total billed charges,50% of total billed charges,13.5,50,,10.8,percent of total billed charges,50% of total billed charges,13.5,50,,10.8,percent of total billed charges,50% of total billed charges,13.5,50,,10.8,percent of total billed charges,50% of total billed charges,18.9,70,,15.12,percent of total billed charges,70% of total billed charges,13.09,48.48,,10.472,percent of total billed charges,48.48% of total billed charges,13.09,48.48,,10.472,percent of total billed charges,48.48% of total billed charges,13.09,48.48,,10.472,percent of total billed charges,48.48% of total billed charges,18.9,70,,15.12,percent of total billed charges,70% of total billed charges,18.9,70,,15.12,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,13.09,48.48,,10.472,percent of total billed charges,48.48% of total billed charges,24.3,90,,19.44,percent of total billed charges,90% of total billed charges,13.09,90,
HURRICANE SPRAY 0.5 ML UD,,,250,RC,,,outpatient,,,57,34.20,,34.2,60,,27.36,percent of total billed charges,60% of total billed charges,27.36,48,,21.888,percent of total billed charges,48% of total billed charges,28.5,50,,22.8,percent of total billed charges,50% of total billed charges,28.5,50,,22.8,percent of total billed charges,50% of total billed charges,28.5,50,,22.8,percent of total billed charges,50% of total billed charges,28.5,50,,22.8,percent of total billed charges,50% of total billed charges,39.9,70,,31.92,percent of total billed charges,70% of total billed charges,27.63,48.48,,22.104,percent of total billed charges,48.48% of total billed charges,27.63,48.48,,22.104,percent of total billed charges,48.48% of total billed charges,27.63,48.48,,22.104,percent of total billed charges,48.48% of total billed charges,39.9,70,,31.92,percent of total billed charges,70% of total billed charges,39.9,70,,31.92,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,27.63,48.48,,22.104,percent of total billed charges,48.48% of total billed charges,51.3,90,,41.04,percent of total billed charges,90% of total billed charges,27.63,90,
METHYLPHENIDATE ER 36 MG,,,259,RC,,,outpatient,,,27,16.20,,16.2,60,,12.96,percent of total billed charges,60% of total billed charges,12.96,48,,10.368,percent of total billed charges,48% of total billed charges,13.5,50,,10.8,percent of total billed charges,50% of total billed charges,13.5,50,,10.8,percent of total billed charges,50% of total billed charges,13.5,50,,10.8,percent of total billed charges,50% of total billed charges,13.5,50,,10.8,percent of total billed charges,50% of total billed charges,18.9,70,,15.12,percent of total billed charges,70% of total billed charges,13.09,48.48,,10.472,percent of total billed charges,48.48% of total billed charges,13.09,48.48,,10.472,percent of total billed charges,48.48% of total billed charges,13.09,48.48,,10.472,percent of total billed charges,48.48% of total billed charges,18.9,70,,15.12,percent of total billed charges,70% of total billed charges,18.9,70,,15.12,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,13.09,48.48,,10.472,percent of total billed charges,48.48% of total billed charges,24.3,90,,19.44,percent of total billed charges,90% of total billed charges,13.09,90,
SOLU CORTEF INJ 100 MG,,,636,RC,J1720,HCPCS,outpatient,1,UN,94,56.40,,56.4,60,,45.12,percent of total billed charges,60% of total billed charges,45.12,48,,36.096,percent of total billed charges,48% of total billed charges,15.57,100,,,fee schedule,100% of bcbs custom fee schedule,15.57,100,,,fee schedule,100% of bcbs custom fee schedule,17.28,111,,,fee schedule,111% of bcbs custom fee schedule,47,50,,37.6,percent of total billed charges,50% of total billed charges,65.8,70,,52.64,percent of total billed charges,70% of total billed charges,45.57,48.48,,36.456,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,45.57,48.48,,36.456,percent of total billed charges,48.48% of total billed charges,65.8,70,,52.64,percent of total billed charges,70% of total billed charges,65.8,70,,52.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,45.57,48.48,,36.456,percent of total billed charges,48.48% of total billed charges,84.6,90,,67.68,percent of total billed charges,90% of total billed charges,45.57,90,
SOLIRIS INJ 300 MG,,,636,RC,J1300,HCPCS,outpatient,,,15656,9393.60,,9393.6,60,,7514.88,percent of total billed charges,60% of total billed charges,7514.88,48,,6011.904,percent of total billed charges,48% of total billed charges,230.48,100,,,fee schedule,100% of bcbs custom fee schedule,230.48,100,,,fee schedule,100% of bcbs custom fee schedule,255.83,111,,,fee schedule,111% of bcbs custom fee schedule,7828,50,,6262.4,percent of total billed charges,50% of total billed charges,10959.2,70,,8767.36,percent of total billed charges,70% of total billed charges,7590.03,48.48,,6072.024,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,7590.03,48.48,,6072.024,percent of total billed charges,48.48% of total billed charges,10959.2,70,,8767.36,percent of total billed charges,70% of total billed charges,10959.2,70,,8767.36,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,7590.03,48.48,,6072.024,percent of total billed charges,48.48% of total billed charges,14090.4,90,,11272.32,percent of total billed charges,90% of total billed charges,48.48,14090.4,
SOLIRIS IVPB 600 MG,,,636,RC,,,outpatient,,,31311,18786.60,,18786.6,60,,15029.28,percent of total billed charges,60% of total billed charges,15029.28,48,,12023.424,percent of total billed charges,48% of total billed charges,15655.5,50,,12524.4,percent of total billed charges,50% of total billed charges,15655.5,50,,12524.4,percent of total billed charges,50% of total billed charges,15655.5,50,,12524.4,percent of total billed charges,50% of total billed charges,15655.5,50,,12524.4,percent of total billed charges,50% of total billed charges,21917.7,70,,17534.16,percent of total billed charges,70% of total billed charges,15179.57,48.48,,12143.656,percent of total billed charges,48.48% of total billed charges,15179.57,48.48,,12143.656,percent of total billed charges,48.48% of total billed charges,15179.57,48.48,,12143.656,percent of total billed charges,48.48% of total billed charges,21917.7,70,,17534.16,percent of total billed charges,70% of total billed charges,21917.7,70,,17534.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,15179.57,48.48,,12143.656,percent of total billed charges,48.48% of total billed charges,28179.9,90,,22543.92,percent of total billed charges,90% of total billed charges,48.48,28179.9,
LEVETIRACETAM 1000 MG PREMIX,,,636,RC,J1953,HCPCS,outpatient,100,UN,216,129.60,,129.6,60,,103.68,percent of total billed charges,60% of total billed charges,103.68,48,,82.944,percent of total billed charges,48% of total billed charges,0.13,100,,,fee schedule,100% of bcbs custom fee schedule,0.13,100,,,fee schedule,100% of bcbs custom fee schedule,0.14,111,,,fee schedule,111% of bcbs custom fee schedule,108,50,,86.4,percent of total billed charges,50% of total billed charges,151.2,70,,120.96,percent of total billed charges,70% of total billed charges,104.72,48.48,,83.776,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,104.72,48.48,,83.776,percent of total billed charges,48.48% of total billed charges,151.2,70,,120.96,percent of total billed charges,70% of total billed charges,151.2,70,,120.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,104.72,48.48,,83.776,percent of total billed charges,48.48% of total billed charges,194.4,90,,155.52,percent of total billed charges,90% of total billed charges,48.48,194.4,
ERAXIS *IVPB* 200 MG,,,636,RC,,,outpatient,,,1815,1089.00,,1089,60,,871.2,percent of total billed charges,60% of total billed charges,871.2,48,,696.96,percent of total billed charges,48% of total billed charges,907.5,50,,726,percent of total billed charges,50% of total billed charges,907.5,50,,726,percent of total billed charges,50% of total billed charges,907.5,50,,726,percent of total billed charges,50% of total billed charges,907.5,50,,726,percent of total billed charges,50% of total billed charges,1270.5,70,,1016.4,percent of total billed charges,70% of total billed charges,879.91,48.48,,703.928,percent of total billed charges,48.48% of total billed charges,879.91,48.48,,703.928,percent of total billed charges,48.48% of total billed charges,879.91,48.48,,703.928,percent of total billed charges,48.48% of total billed charges,1270.5,70,,1016.4,percent of total billed charges,70% of total billed charges,1270.5,70,,1016.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,879.91,48.48,,703.928,percent of total billed charges,48.48% of total billed charges,1633.5,90,,1306.8,percent of total billed charges,90% of total billed charges,48.48,1633.5,
BAXDELA *IVPB* 300 MG,,,636,RC,J3490,HCPCS,outpatient,1,UN,662,397.20,,397.2,60,,317.76,percent of total billed charges,60% of total billed charges,317.76,48,,254.208,percent of total billed charges,48% of total billed charges,331,50,,264.8,percent of total billed charges,50% of total billed charges,331,50,,264.8,percent of total billed charges,50% of total billed charges,331,50,,264.8,percent of total billed charges,50% of total billed charges,331,50,,264.8,percent of total billed charges,50% of total billed charges,463.4,70,,370.72,percent of total billed charges,70% of total billed charges,320.94,48.48,,256.752,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,320.94,48.48,,256.752,percent of total billed charges,48.48% of total billed charges,463.4,70,,370.72,percent of total billed charges,70% of total billed charges,463.4,70,,370.72,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,320.94,48.48,,256.752,percent of total billed charges,48.48% of total billed charges,595.8,90,,476.64,percent of total billed charges,90% of total billed charges,48.48,595.8,
CLOBETASOL CRM 0.05%,,,259,RC,,,outpatient,,,513,307.80,,307.8,60,,246.24,percent of total billed charges,60% of total billed charges,246.24,48,,196.992,percent of total billed charges,48% of total billed charges,256.5,50,,205.2,percent of total billed charges,50% of total billed charges,256.5,50,,205.2,percent of total billed charges,50% of total billed charges,256.5,50,,205.2,percent of total billed charges,50% of total billed charges,256.5,50,,205.2,percent of total billed charges,50% of total billed charges,359.1,70,,287.28,percent of total billed charges,70% of total billed charges,248.7,48.48,,198.96,percent of total billed charges,48.48% of total billed charges,248.7,48.48,,198.96,percent of total billed charges,48.48% of total billed charges,248.7,48.48,,198.96,percent of total billed charges,48.48% of total billed charges,359.1,70,,287.28,percent of total billed charges,70% of total billed charges,359.1,70,,287.28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,248.7,48.48,,198.96,percent of total billed charges,48.48% of total billed charges,461.7,90,,369.36,percent of total billed charges,90% of total billed charges,48.48,461.7,
BETAMETHASONE D CR .05%,,,250,RC,,,outpatient,,,222,133.20,,133.2,60,,106.56,percent of total billed charges,60% of total billed charges,106.56,48,,85.248,percent of total billed charges,48% of total billed charges,111,50,,88.8,percent of total billed charges,50% of total billed charges,111,50,,88.8,percent of total billed charges,50% of total billed charges,111,50,,88.8,percent of total billed charges,50% of total billed charges,111,50,,88.8,percent of total billed charges,50% of total billed charges,155.4,70,,124.32,percent of total billed charges,70% of total billed charges,107.63,48.48,,86.104,percent of total billed charges,48.48% of total billed charges,107.63,48.48,,86.104,percent of total billed charges,48.48% of total billed charges,107.63,48.48,,86.104,percent of total billed charges,48.48% of total billed charges,155.4,70,,124.32,percent of total billed charges,70% of total billed charges,155.4,70,,124.32,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,107.63,48.48,,86.104,percent of total billed charges,48.48% of total billed charges,199.8,90,,159.84,percent of total billed charges,90% of total billed charges,48.48,199.8,
ADENOSINE INJ 6 MG,,,636,RC,,,outpatient,,,53,31.80,,31.8,60,,25.44,percent of total billed charges,60% of total billed charges,25.44,48,,20.352,percent of total billed charges,48% of total billed charges,26.5,50,,21.2,percent of total billed charges,50% of total billed charges,26.5,50,,21.2,percent of total billed charges,50% of total billed charges,26.5,50,,21.2,percent of total billed charges,50% of total billed charges,26.5,50,,21.2,percent of total billed charges,50% of total billed charges,37.1,70,,29.68,percent of total billed charges,70% of total billed charges,25.69,48.48,,20.552,percent of total billed charges,48.48% of total billed charges,25.69,48.48,,20.552,percent of total billed charges,48.48% of total billed charges,25.69,48.48,,20.552,percent of total billed charges,48.48% of total billed charges,37.1,70,,29.68,percent of total billed charges,70% of total billed charges,37.1,70,,29.68,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,25.69,48.48,,20.552,percent of total billed charges,48.48% of total billed charges,47.7,90,,38.16,percent of total billed charges,90% of total billed charges,25.69,90,
ADENOSINE INJ 12 MG,,,636,RC,,,outpatient,,,125,75.00,,75,60,,60,percent of total billed charges,60% of total billed charges,60,48,,48,percent of total billed charges,48% of total billed charges,62.5,50,,50,percent of total billed charges,50% of total billed charges,62.5,50,,50,percent of total billed charges,50% of total billed charges,62.5,50,,50,percent of total billed charges,50% of total billed charges,62.5,50,,50,percent of total billed charges,50% of total billed charges,87.5,70,,70,percent of total billed charges,70% of total billed charges,60.6,48.48,,48.48,percent of total billed charges,48.48% of total billed charges,60.6,48.48,,48.48,percent of total billed charges,48.48% of total billed charges,60.6,48.48,,48.48,percent of total billed charges,48.48% of total billed charges,87.5,70,,70,percent of total billed charges,70% of total billed charges,87.5,70,,70,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,60.6,48.48,,48.48,percent of total billed charges,48.48% of total billed charges,112.5,90,,90,percent of total billed charges,90% of total billed charges,48.48,112.5,
TRELEGY INH,,,250,RC,,,outpatient,,,1347,808.20,,808.2,60,,646.56,percent of total billed charges,60% of total billed charges,646.56,48,,517.248,percent of total billed charges,48% of total billed charges,673.5,50,,538.8,percent of total billed charges,50% of total billed charges,673.5,50,,538.8,percent of total billed charges,50% of total billed charges,673.5,50,,538.8,percent of total billed charges,50% of total billed charges,673.5,50,,538.8,percent of total billed charges,50% of total billed charges,942.9,70,,754.32,percent of total billed charges,70% of total billed charges,653.03,48.48,,522.424,percent of total billed charges,48.48% of total billed charges,653.03,48.48,,522.424,percent of total billed charges,48.48% of total billed charges,653.03,48.48,,522.424,percent of total billed charges,48.48% of total billed charges,942.9,70,,754.32,percent of total billed charges,70% of total billed charges,942.9,70,,754.32,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,653.03,48.48,,522.424,percent of total billed charges,48.48% of total billed charges,1212.3,90,,969.84,percent of total billed charges,90% of total billed charges,48.48,1212.3,
SUPREP BOWEL PREP KIT,,,250,RC,,,outpatient,,,517,310.20,,310.2,60,,248.16,percent of total billed charges,60% of total billed charges,248.16,48,,198.528,percent of total billed charges,48% of total billed charges,258.5,50,,206.8,percent of total billed charges,50% of total billed charges,258.5,50,,206.8,percent of total billed charges,50% of total billed charges,258.5,50,,206.8,percent of total billed charges,50% of total billed charges,258.5,50,,206.8,percent of total billed charges,50% of total billed charges,361.9,70,,289.52,percent of total billed charges,70% of total billed charges,250.64,48.48,,200.512,percent of total billed charges,48.48% of total billed charges,250.64,48.48,,200.512,percent of total billed charges,48.48% of total billed charges,250.64,48.48,,200.512,percent of total billed charges,48.48% of total billed charges,361.9,70,,289.52,percent of total billed charges,70% of total billed charges,361.9,70,,289.52,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,250.64,48.48,,200.512,percent of total billed charges,48.48% of total billed charges,465.3,90,,372.24,percent of total billed charges,90% of total billed charges,48.48,465.3,
SHINGRIX 50MCG INJ,43601427,CDM,250,RC,90750,HCPCS,outpatient,1,UN,389,233.40,,233.4,60,,186.72,percent of total billed charges,60% of total billed charges,186.72,48,,149.376,percent of total billed charges,48% of total billed charges,172.61,100,,,fee schedule,100% of bcbs custom fee schedule,172.61,100,,,fee schedule,100% of bcbs custom fee schedule,191.6,111,,,fee schedule,111% of bcbs custom fee schedule,194.5,50,,155.6,percent of total billed charges,50% of total billed charges,272.3,70,,217.84,percent of total billed charges,70% of total billed charges,188.59,48.48,,150.872,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,188.59,48.48,,150.872,percent of total billed charges,48.48% of total billed charges,272.3,70,,217.84,percent of total billed charges,70% of total billed charges,272.3,70,,217.84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,188.59,48.48,,150.872,percent of total billed charges,48.48% of total billed charges,350.1,90,,280.08,percent of total billed charges,90% of total billed charges,48.48,350.1,
CLINIMIX-E 2.75/10,,,250,RC,,,outpatient,,,187,112.20,,112.2,60,,89.76,percent of total billed charges,60% of total billed charges,89.76,48,,71.808,percent of total billed charges,48% of total billed charges,93.5,50,,74.8,percent of total billed charges,50% of total billed charges,93.5,50,,74.8,percent of total billed charges,50% of total billed charges,93.5,50,,74.8,percent of total billed charges,50% of total billed charges,93.5,50,,74.8,percent of total billed charges,50% of total billed charges,130.9,70,,104.72,percent of total billed charges,70% of total billed charges,90.66,48.48,,72.528,percent of total billed charges,48.48% of total billed charges,90.66,48.48,,72.528,percent of total billed charges,48.48% of total billed charges,90.66,48.48,,72.528,percent of total billed charges,48.48% of total billed charges,130.9,70,,104.72,percent of total billed charges,70% of total billed charges,130.9,70,,104.72,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,90.66,48.48,,72.528,percent of total billed charges,48.48% of total billed charges,168.3,90,,134.64,percent of total billed charges,90% of total billed charges,48.48,168.3,
CEFEPIME 1GM/D5 50 PREMIX,,,636,RC,J0692,HCPCS,outpatient,2,UN,95,57.00,,57,60,,45.6,percent of total billed charges,60% of total billed charges,45.6,48,,36.48,percent of total billed charges,48% of total billed charges,1.86,100,,,fee schedule,100% of bcbs custom fee schedule,1.86,100,,,fee schedule,100% of bcbs custom fee schedule,2.06,111,,,fee schedule,111% of bcbs custom fee schedule,47.5,50,,38,percent of total billed charges,50% of total billed charges,66.5,70,,53.2,percent of total billed charges,70% of total billed charges,46.06,48.48,,36.848,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,46.06,48.48,,36.848,percent of total billed charges,48.48% of total billed charges,66.5,70,,53.2,percent of total billed charges,70% of total billed charges,66.5,70,,53.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,46.06,48.48,,36.848,percent of total billed charges,48.48% of total billed charges,85.5,90,,68.4,percent of total billed charges,90% of total billed charges,46.06,90,
TAMBOCOR 50 MG,,,259,RC,,,outpatient,,,17,10.20,,10.2,60,,8.16,percent of total billed charges,60% of total billed charges,8.16,48,,6.528,percent of total billed charges,48% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,11.9,70,,9.52,percent of total billed charges,70% of total billed charges,8.24,48.48,,6.592,percent of total billed charges,48.48% of total billed charges,8.24,48.48,,6.592,percent of total billed charges,48.48% of total billed charges,8.24,48.48,,6.592,percent of total billed charges,48.48% of total billed charges,11.9,70,,9.52,percent of total billed charges,70% of total billed charges,11.9,70,,9.52,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,8.24,48.48,,6.592,percent of total billed charges,48.48% of total billed charges,15.3,90,,12.24,percent of total billed charges,90% of total billed charges,8.24,90,
RIFAMPIN CAP 150 MG,,,259,RC,,,outpatient,,,13,7.80,,7.8,60,,6.24,percent of total billed charges,60% of total billed charges,6.24,48,,4.992,percent of total billed charges,48% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,9.1,70,,7.28,percent of total billed charges,70% of total billed charges,6.3,48.48,,5.04,percent of total billed charges,48.48% of total billed charges,6.3,48.48,,5.04,percent of total billed charges,48.48% of total billed charges,6.3,48.48,,5.04,percent of total billed charges,48.48% of total billed charges,9.1,70,,7.28,percent of total billed charges,70% of total billed charges,9.1,70,,7.28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,6.3,48.48,,5.04,percent of total billed charges,48.48% of total billed charges,11.7,90,,9.36,percent of total billed charges,90% of total billed charges,6.3,90,
XIGDUO 5/1000 MG,,,259,RC,,,outpatient,,,43,25.80,,25.8,60,,20.64,percent of total billed charges,60% of total billed charges,20.64,48,,16.512,percent of total billed charges,48% of total billed charges,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,30.1,70,,24.08,percent of total billed charges,70% of total billed charges,20.85,48.48,,16.68,percent of total billed charges,48.48% of total billed charges,20.85,48.48,,16.68,percent of total billed charges,48.48% of total billed charges,20.85,48.48,,16.68,percent of total billed charges,48.48% of total billed charges,30.1,70,,24.08,percent of total billed charges,70% of total billed charges,30.1,70,,24.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,20.85,48.48,,16.68,percent of total billed charges,48.48% of total billed charges,38.7,90,,30.96,percent of total billed charges,90% of total billed charges,20.85,90,
INFLUENZA VACC [FLUBLOK],,,636,RC,90673,HCPCS,outpatient,1,UN,90,54.00,,54,60,,43.2,percent of total billed charges,60% of total billed charges,43.2,48,,34.56,percent of total billed charges,48% of total billed charges,40.61,100,,,fee schedule,100% of bcbs custom fee schedule,40.61,100,,,fee schedule,100% of bcbs custom fee schedule,45.08,111,,,fee schedule,111% of bcbs custom fee schedule,45,50,,36,percent of total billed charges,50% of total billed charges,63,70,,50.4,percent of total billed charges,70% of total billed charges,43.63,48.48,,34.904,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,43.63,48.48,,34.904,percent of total billed charges,48.48% of total billed charges,63,70,,50.4,percent of total billed charges,70% of total billed charges,63,70,,50.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,43.63,48.48,,34.904,percent of total billed charges,48.48% of total billed charges,81,90,,64.8,percent of total billed charges,90% of total billed charges,43.63,90,
MAG SULF 1 G/100ML PREMIX,,,636,RC,J3475,HCPCS,outpatient,1,UN,40,24.00,,24,60,,19.2,percent of total billed charges,60% of total billed charges,19.2,48,,15.36,percent of total billed charges,48% of total billed charges,0.46,100,,,fee schedule,100% of bcbs custom fee schedule,0.46,100,,,fee schedule,100% of bcbs custom fee schedule,0.51,111,,,fee schedule,111% of bcbs custom fee schedule,20,50,,16,percent of total billed charges,50% of total billed charges,28,70,,22.4,percent of total billed charges,70% of total billed charges,19.39,48.48,,15.512,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,19.39,48.48,,15.512,percent of total billed charges,48.48% of total billed charges,28,70,,22.4,percent of total billed charges,70% of total billed charges,28,70,,22.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,19.39,48.48,,15.512,percent of total billed charges,48.48% of total billed charges,36,90,,28.8,percent of total billed charges,90% of total billed charges,19.39,90,
MIDAZOLAM 5MG/ML (INTRANASAL USE),,,636,RC,,,outpatient,,,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
XARELTO TAB 15 MG,,,259,RC,,,outpatient,,,79,47.40,,47.4,60,,37.92,percent of total billed charges,60% of total billed charges,37.92,48,,30.336,percent of total billed charges,48% of total billed charges,39.5,50,,31.6,percent of total billed charges,50% of total billed charges,39.5,50,,31.6,percent of total billed charges,50% of total billed charges,39.5,50,,31.6,percent of total billed charges,50% of total billed charges,39.5,50,,31.6,percent of total billed charges,50% of total billed charges,55.3,70,,44.24,percent of total billed charges,70% of total billed charges,38.3,48.48,,30.64,percent of total billed charges,48.48% of total billed charges,38.3,48.48,,30.64,percent of total billed charges,48.48% of total billed charges,38.3,48.48,,30.64,percent of total billed charges,48.48% of total billed charges,55.3,70,,44.24,percent of total billed charges,70% of total billed charges,55.3,70,,44.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,38.3,48.48,,30.64,percent of total billed charges,48.48% of total billed charges,71.1,90,,56.88,percent of total billed charges,90% of total billed charges,38.3,90,
THEOPHYLLINE SOL 80MG [480 ML],,,250,RC,,,outpatient,,,447,268.20,,268.2,60,,214.56,percent of total billed charges,60% of total billed charges,214.56,48,,171.648,percent of total billed charges,48% of total billed charges,223.5,50,,178.8,percent of total billed charges,50% of total billed charges,223.5,50,,178.8,percent of total billed charges,50% of total billed charges,223.5,50,,178.8,percent of total billed charges,50% of total billed charges,223.5,50,,178.8,percent of total billed charges,50% of total billed charges,312.9,70,,250.32,percent of total billed charges,70% of total billed charges,216.71,48.48,,173.368,percent of total billed charges,48.48% of total billed charges,216.71,48.48,,173.368,percent of total billed charges,48.48% of total billed charges,216.71,48.48,,173.368,percent of total billed charges,48.48% of total billed charges,312.9,70,,250.32,percent of total billed charges,70% of total billed charges,312.9,70,,250.32,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,216.71,48.48,,173.368,percent of total billed charges,48.48% of total billed charges,402.3,90,,321.84,percent of total billed charges,90% of total billed charges,48.48,402.3,
METANX CAPSULE,,,259,RC,,,outpatient,,,15,9.00,,9,60,,7.2,percent of total billed charges,60% of total billed charges,7.2,48,,5.76,percent of total billed charges,48% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,13.5,90,,10.8,percent of total billed charges,90% of total billed charges,7.27,90,
OXYCONTIN CR 60 MG,,,259,RC,,,outpatient,,,99,59.40,,59.4,60,,47.52,percent of total billed charges,60% of total billed charges,47.52,48,,38.016,percent of total billed charges,48% of total billed charges,49.5,50,,39.6,percent of total billed charges,50% of total billed charges,49.5,50,,39.6,percent of total billed charges,50% of total billed charges,49.5,50,,39.6,percent of total billed charges,50% of total billed charges,49.5,50,,39.6,percent of total billed charges,50% of total billed charges,69.3,70,,55.44,percent of total billed charges,70% of total billed charges,48,48.48,,38.4,percent of total billed charges,48.48% of total billed charges,48,48.48,,38.4,percent of total billed charges,48.48% of total billed charges,48,48.48,,38.4,percent of total billed charges,48.48% of total billed charges,69.3,70,,55.44,percent of total billed charges,70% of total billed charges,69.3,70,,55.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,48,48.48,,38.4,percent of total billed charges,48.48% of total billed charges,89.1,90,,71.28,percent of total billed charges,90% of total billed charges,48,90,
VICTOZA 18 MG PEN,,,250,RC,,,outpatient,,,1475,885.00,,885,60,,708,percent of total billed charges,60% of total billed charges,708,48,,566.4,percent of total billed charges,48% of total billed charges,737.5,50,,590,percent of total billed charges,50% of total billed charges,737.5,50,,590,percent of total billed charges,50% of total billed charges,737.5,50,,590,percent of total billed charges,50% of total billed charges,737.5,50,,590,percent of total billed charges,50% of total billed charges,1032.5,70,,826,percent of total billed charges,70% of total billed charges,715.08,48.48,,572.064,percent of total billed charges,48.48% of total billed charges,715.08,48.48,,572.064,percent of total billed charges,48.48% of total billed charges,715.08,48.48,,572.064,percent of total billed charges,48.48% of total billed charges,1032.5,70,,826,percent of total billed charges,70% of total billed charges,1032.5,70,,826,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,715.08,48.48,,572.064,percent of total billed charges,48.48% of total billed charges,1327.5,90,,1062,percent of total billed charges,90% of total billed charges,48.48,1327.5,
TRESIBA FLEXTOUCH,,,250,RC,,,outpatient,,,489,293.40,,293.4,60,,234.72,percent of total billed charges,60% of total billed charges,234.72,48,,187.776,percent of total billed charges,48% of total billed charges,244.5,50,,195.6,percent of total billed charges,50% of total billed charges,244.5,50,,195.6,percent of total billed charges,50% of total billed charges,244.5,50,,195.6,percent of total billed charges,50% of total billed charges,244.5,50,,195.6,percent of total billed charges,50% of total billed charges,342.3,70,,273.84,percent of total billed charges,70% of total billed charges,237.07,48.48,,189.656,percent of total billed charges,48.48% of total billed charges,237.07,48.48,,189.656,percent of total billed charges,48.48% of total billed charges,237.07,48.48,,189.656,percent of total billed charges,48.48% of total billed charges,342.3,70,,273.84,percent of total billed charges,70% of total billed charges,342.3,70,,273.84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,237.07,48.48,,189.656,percent of total billed charges,48.48% of total billed charges,440.1,90,,352.08,percent of total billed charges,90% of total billed charges,48.48,440.1,
ASPERCREME/LIDOCAINE,,,250,RC,,,outpatient,,,29,17.40,,17.4,60,,13.92,percent of total billed charges,60% of total billed charges,13.92,48,,11.136,percent of total billed charges,48% of total billed charges,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,20.3,70,,16.24,percent of total billed charges,70% of total billed charges,14.06,48.48,,11.248,percent of total billed charges,48.48% of total billed charges,14.06,48.48,,11.248,percent of total billed charges,48.48% of total billed charges,14.06,48.48,,11.248,percent of total billed charges,48.48% of total billed charges,20.3,70,,16.24,percent of total billed charges,70% of total billed charges,20.3,70,,16.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,14.06,48.48,,11.248,percent of total billed charges,48.48% of total billed charges,26.1,90,,20.88,percent of total billed charges,90% of total billed charges,14.06,90,
ENTRESTO TAB [49MG/51MG],,,259,RC,,,outpatient,,,47,28.20,,28.2,60,,22.56,percent of total billed charges,60% of total billed charges,22.56,48,,18.048,percent of total billed charges,48% of total billed charges,23.5,50,,18.8,percent of total billed charges,50% of total billed charges,23.5,50,,18.8,percent of total billed charges,50% of total billed charges,23.5,50,,18.8,percent of total billed charges,50% of total billed charges,23.5,50,,18.8,percent of total billed charges,50% of total billed charges,32.9,70,,26.32,percent of total billed charges,70% of total billed charges,22.79,48.48,,18.232,percent of total billed charges,48.48% of total billed charges,22.79,48.48,,18.232,percent of total billed charges,48.48% of total billed charges,22.79,48.48,,18.232,percent of total billed charges,48.48% of total billed charges,32.9,70,,26.32,percent of total billed charges,70% of total billed charges,32.9,70,,26.32,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,22.79,48.48,,18.232,percent of total billed charges,48.48% of total billed charges,42.3,90,,33.84,percent of total billed charges,90% of total billed charges,22.79,90,
ENTRESTO TAB [97MG/103MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,56,33.60,,33.6,60,,26.88,percent of total billed charges,60% of total billed charges,26.88,48,,21.504,percent of total billed charges,48% of total billed charges,28,50,,22.4,percent of total billed charges,50% of total billed charges,28,50,,22.4,percent of total billed charges,50% of total billed charges,28,50,,22.4,percent of total billed charges,50% of total billed charges,28,50,,22.4,percent of total billed charges,50% of total billed charges,39.2,70,,31.36,percent of total billed charges,70% of total billed charges,27.15,48.48,,21.72,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,27.15,48.48,,21.72,percent of total billed charges,48.48% of total billed charges,39.2,70,,31.36,percent of total billed charges,70% of total billed charges,39.2,70,,31.36,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,27.15,48.48,,21.72,percent of total billed charges,48.48% of total billed charges,50.4,90,,40.32,percent of total billed charges,90% of total billed charges,27.15,90,
ORBACTIV INJ [1200 MG],,,636,RC,,,outpatient,,,6960,4176.00,,4176,60,,3340.8,percent of total billed charges,60% of total billed charges,3340.8,48,,2672.64,percent of total billed charges,48% of total billed charges,3480,50,,2784,percent of total billed charges,50% of total billed charges,3480,50,,2784,percent of total billed charges,50% of total billed charges,3480,50,,2784,percent of total billed charges,50% of total billed charges,3480,50,,2784,percent of total billed charges,50% of total billed charges,4872,70,,3897.6,percent of total billed charges,70% of total billed charges,3374.21,48.48,,2699.368,percent of total billed charges,48.48% of total billed charges,3374.21,48.48,,2699.368,percent of total billed charges,48.48% of total billed charges,3374.21,48.48,,2699.368,percent of total billed charges,48.48% of total billed charges,4872,70,,3897.6,percent of total billed charges,70% of total billed charges,4872,70,,3897.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,3374.21,48.48,,2699.368,percent of total billed charges,48.48% of total billed charges,6264,90,,5011.2,percent of total billed charges,90% of total billed charges,48.48,6264,
CLINIMIX E 5/20 1000 ML,,,636,RC,B4189,HCPCS,outpatient,1,UN,218,130.80,,130.8,60,,104.64,percent of total billed charges,60% of total billed charges,104.64,48,,83.712,percent of total billed charges,48% of total billed charges,135.04,100,,,fee schedule,100% of bcbs custom fee schedule,135.04,100,,,fee schedule,100% of bcbs custom fee schedule,149.89,111,,,fee schedule,111% of bcbs custom fee schedule,109,50,,87.2,percent of total billed charges,50% of total billed charges,152.6,70,,122.08,percent of total billed charges,70% of total billed charges,105.69,48.48,,84.552,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,105.69,48.48,,84.552,percent of total billed charges,48.48% of total billed charges,152.6,70,,122.08,percent of total billed charges,70% of total billed charges,152.6,70,,122.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,105.69,48.48,,84.552,percent of total billed charges,48.48% of total billed charges,196.2,90,,156.96,percent of total billed charges,90% of total billed charges,48.48,196.2,
TRANEXAMIC INJ 1000 MG/10 ML,,,250,RC,,,outpatient,,,35,21.00,,21,60,,16.8,percent of total billed charges,60% of total billed charges,16.8,48,,13.44,percent of total billed charges,48% of total billed charges,17.5,50,,14,percent of total billed charges,50% of total billed charges,17.5,50,,14,percent of total billed charges,50% of total billed charges,17.5,50,,14,percent of total billed charges,50% of total billed charges,17.5,50,,14,percent of total billed charges,50% of total billed charges,24.5,70,,19.6,percent of total billed charges,70% of total billed charges,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,24.5,70,,19.6,percent of total billed charges,70% of total billed charges,24.5,70,,19.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,31.5,90,,25.2,percent of total billed charges,90% of total billed charges,16.97,90,
SAW PALMETTO 160 MG 30CT,,,259,RC,,,outpatient,,,27,16.20,,16.2,60,,12.96,percent of total billed charges,60% of total billed charges,12.96,48,,10.368,percent of total billed charges,48% of total billed charges,13.5,50,,10.8,percent of total billed charges,50% of total billed charges,13.5,50,,10.8,percent of total billed charges,50% of total billed charges,13.5,50,,10.8,percent of total billed charges,50% of total billed charges,13.5,50,,10.8,percent of total billed charges,50% of total billed charges,18.9,70,,15.12,percent of total billed charges,70% of total billed charges,13.09,48.48,,10.472,percent of total billed charges,48.48% of total billed charges,13.09,48.48,,10.472,percent of total billed charges,48.48% of total billed charges,13.09,48.48,,10.472,percent of total billed charges,48.48% of total billed charges,18.9,70,,15.12,percent of total billed charges,70% of total billed charges,18.9,70,,15.12,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,13.09,48.48,,10.472,percent of total billed charges,48.48% of total billed charges,24.3,90,,19.44,percent of total billed charges,90% of total billed charges,13.09,90,
NUVIGIL TAB 150 MG,,,259,RC,,,outpatient,,,88,52.80,,52.8,60,,42.24,percent of total billed charges,60% of total billed charges,42.24,48,,33.792,percent of total billed charges,48% of total billed charges,44,50,,35.2,percent of total billed charges,50% of total billed charges,44,50,,35.2,percent of total billed charges,50% of total billed charges,44,50,,35.2,percent of total billed charges,50% of total billed charges,44,50,,35.2,percent of total billed charges,50% of total billed charges,61.6,70,,49.28,percent of total billed charges,70% of total billed charges,42.66,48.48,,34.128,percent of total billed charges,48.48% of total billed charges,42.66,48.48,,34.128,percent of total billed charges,48.48% of total billed charges,42.66,48.48,,34.128,percent of total billed charges,48.48% of total billed charges,61.6,70,,49.28,percent of total billed charges,70% of total billed charges,61.6,70,,49.28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,42.66,48.48,,34.128,percent of total billed charges,48.48% of total billed charges,79.2,90,,63.36,percent of total billed charges,90% of total billed charges,42.66,90,
BREO ELLIPTA INH,,,259,RC,,,outpatient,,,464,278.40,,278.4,60,,222.72,percent of total billed charges,60% of total billed charges,222.72,48,,178.176,percent of total billed charges,48% of total billed charges,232,50,,185.6,percent of total billed charges,50% of total billed charges,232,50,,185.6,percent of total billed charges,50% of total billed charges,232,50,,185.6,percent of total billed charges,50% of total billed charges,232,50,,185.6,percent of total billed charges,50% of total billed charges,324.8,70,,259.84,percent of total billed charges,70% of total billed charges,224.95,48.48,,179.96,percent of total billed charges,48.48% of total billed charges,224.95,48.48,,179.96,percent of total billed charges,48.48% of total billed charges,224.95,48.48,,179.96,percent of total billed charges,48.48% of total billed charges,324.8,70,,259.84,percent of total billed charges,70% of total billed charges,324.8,70,,259.84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,224.95,48.48,,179.96,percent of total billed charges,48.48% of total billed charges,417.6,90,,334.08,percent of total billed charges,90% of total billed charges,48.48,417.6,
DESMOPRESSIN TAB 0.1 MG,,,259,RC,,,outpatient,,,13,7.80,,7.8,60,,6.24,percent of total billed charges,60% of total billed charges,6.24,48,,4.992,percent of total billed charges,48% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,9.1,70,,7.28,percent of total billed charges,70% of total billed charges,6.3,48.48,,5.04,percent of total billed charges,48.48% of total billed charges,6.3,48.48,,5.04,percent of total billed charges,48.48% of total billed charges,6.3,48.48,,5.04,percent of total billed charges,48.48% of total billed charges,9.1,70,,7.28,percent of total billed charges,70% of total billed charges,9.1,70,,7.28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,6.3,48.48,,5.04,percent of total billed charges,48.48% of total billed charges,11.7,90,,9.36,percent of total billed charges,90% of total billed charges,6.3,90,
SOLIRIS IVPB 900 MG,,,636,RC,,,outpatient,,,46966,28179.60,,28179.6,60,,22543.68,percent of total billed charges,60% of total billed charges,22543.68,48,,18034.944,percent of total billed charges,48% of total billed charges,23483,50,,18786.4,percent of total billed charges,50% of total billed charges,23483,50,,18786.4,percent of total billed charges,50% of total billed charges,23483,50,,18786.4,percent of total billed charges,50% of total billed charges,23483,50,,18786.4,percent of total billed charges,50% of total billed charges,32876.2,70,,26300.96,percent of total billed charges,70% of total billed charges,22769.12,48.48,,18215.296,percent of total billed charges,48.48% of total billed charges,22769.12,48.48,,18215.296,percent of total billed charges,48.48% of total billed charges,22769.12,48.48,,18215.296,percent of total billed charges,48.48% of total billed charges,32876.2,70,,26300.96,percent of total billed charges,70% of total billed charges,32876.2,70,,26300.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,22769.12,48.48,,18215.296,percent of total billed charges,48.48% of total billed charges,42269.4,90,,33815.52,percent of total billed charges,90% of total billed charges,48.48,42269.4,
AQUAPHOR LIP BALM,,,259,RC,,,outpatient,,,18,10.80,,10.8,60,,8.64,percent of total billed charges,60% of total billed charges,8.64,48,,6.912,percent of total billed charges,48% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,12.6,70,,10.08,percent of total billed charges,70% of total billed charges,8.73,48.48,,6.984,percent of total billed charges,48.48% of total billed charges,8.73,48.48,,6.984,percent of total billed charges,48.48% of total billed charges,8.73,48.48,,6.984,percent of total billed charges,48.48% of total billed charges,12.6,70,,10.08,percent of total billed charges,70% of total billed charges,12.6,70,,10.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,8.73,48.48,,6.984,percent of total billed charges,48.48% of total billed charges,16.2,90,,12.96,percent of total billed charges,90% of total billed charges,8.73,90,
ASPERCREME 1.25 OZ,,,250,RC,,,outpatient,,,15,9.00,,9,60,,7.2,percent of total billed charges,60% of total billed charges,7.2,48,,5.76,percent of total billed charges,48% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,13.5,90,,10.8,percent of total billed charges,90% of total billed charges,7.27,90,
BAXDELA TAB 450 MG,,,259,RC,,,outpatient,,,358,214.80,,214.8,60,,171.84,percent of total billed charges,60% of total billed charges,171.84,48,,137.472,percent of total billed charges,48% of total billed charges,179,50,,143.2,percent of total billed charges,50% of total billed charges,179,50,,143.2,percent of total billed charges,50% of total billed charges,179,50,,143.2,percent of total billed charges,50% of total billed charges,179,50,,143.2,percent of total billed charges,50% of total billed charges,250.6,70,,200.48,percent of total billed charges,70% of total billed charges,173.56,48.48,,138.848,percent of total billed charges,48.48% of total billed charges,173.56,48.48,,138.848,percent of total billed charges,48.48% of total billed charges,173.56,48.48,,138.848,percent of total billed charges,48.48% of total billed charges,250.6,70,,200.48,percent of total billed charges,70% of total billed charges,250.6,70,,200.48,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,173.56,48.48,,138.848,percent of total billed charges,48.48% of total billed charges,322.2,90,,257.76,percent of total billed charges,90% of total billed charges,48.48,322.2,
MONUROL PKT,,,250,RC,,,outpatient,,,418,250.80,,250.8,60,,200.64,percent of total billed charges,60% of total billed charges,200.64,48,,160.512,percent of total billed charges,48% of total billed charges,209,50,,167.2,percent of total billed charges,50% of total billed charges,209,50,,167.2,percent of total billed charges,50% of total billed charges,209,50,,167.2,percent of total billed charges,50% of total billed charges,209,50,,167.2,percent of total billed charges,50% of total billed charges,292.6,70,,234.08,percent of total billed charges,70% of total billed charges,202.65,48.48,,162.12,percent of total billed charges,48.48% of total billed charges,202.65,48.48,,162.12,percent of total billed charges,48.48% of total billed charges,202.65,48.48,,162.12,percent of total billed charges,48.48% of total billed charges,292.6,70,,234.08,percent of total billed charges,70% of total billed charges,292.6,70,,234.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,202.65,48.48,,162.12,percent of total billed charges,48.48% of total billed charges,376.2,90,,300.96,percent of total billed charges,90% of total billed charges,48.48,376.2,
TUCKS PADS 100#,,,259,RC,,,outpatient,,,31,18.60,,18.6,60,,14.88,percent of total billed charges,60% of total billed charges,14.88,48,,11.904,percent of total billed charges,48% of total billed charges,15.5,50,,12.4,percent of total billed charges,50% of total billed charges,15.5,50,,12.4,percent of total billed charges,50% of total billed charges,15.5,50,,12.4,percent of total billed charges,50% of total billed charges,15.5,50,,12.4,percent of total billed charges,50% of total billed charges,21.7,70,,17.36,percent of total billed charges,70% of total billed charges,15.03,48.48,,12.024,percent of total billed charges,48.48% of total billed charges,15.03,48.48,,12.024,percent of total billed charges,48.48% of total billed charges,15.03,48.48,,12.024,percent of total billed charges,48.48% of total billed charges,21.7,70,,17.36,percent of total billed charges,70% of total billed charges,21.7,70,,17.36,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,15.03,48.48,,12.024,percent of total billed charges,48.48% of total billed charges,27.9,90,,22.32,percent of total billed charges,90% of total billed charges,15.03,90,
EFFIENT TAB 5 MG,,,259,RC,,,outpatient,,,74,44.40,,44.4,60,,35.52,percent of total billed charges,60% of total billed charges,35.52,48,,28.416,percent of total billed charges,48% of total billed charges,37,50,,29.6,percent of total billed charges,50% of total billed charges,37,50,,29.6,percent of total billed charges,50% of total billed charges,37,50,,29.6,percent of total billed charges,50% of total billed charges,37,50,,29.6,percent of total billed charges,50% of total billed charges,51.8,70,,41.44,percent of total billed charges,70% of total billed charges,35.88,48.48,,28.704,percent of total billed charges,48.48% of total billed charges,35.88,48.48,,28.704,percent of total billed charges,48.48% of total billed charges,35.88,48.48,,28.704,percent of total billed charges,48.48% of total billed charges,51.8,70,,41.44,percent of total billed charges,70% of total billed charges,51.8,70,,41.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,35.88,48.48,,28.704,percent of total billed charges,48.48% of total billed charges,66.6,90,,53.28,percent of total billed charges,90% of total billed charges,35.88,90,
FARXIGA TAB 10 MG,,,259,RC,,,outpatient,,,86,51.60,,51.6,60,,41.28,percent of total billed charges,60% of total billed charges,41.28,48,,33.024,percent of total billed charges,48% of total billed charges,43,50,,34.4,percent of total billed charges,50% of total billed charges,43,50,,34.4,percent of total billed charges,50% of total billed charges,43,50,,34.4,percent of total billed charges,50% of total billed charges,43,50,,34.4,percent of total billed charges,50% of total billed charges,60.2,70,,48.16,percent of total billed charges,70% of total billed charges,41.69,48.48,,33.352,percent of total billed charges,48.48% of total billed charges,41.69,48.48,,33.352,percent of total billed charges,48.48% of total billed charges,41.69,48.48,,33.352,percent of total billed charges,48.48% of total billed charges,60.2,70,,48.16,percent of total billed charges,70% of total billed charges,60.2,70,,48.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,41.69,48.48,,33.352,percent of total billed charges,48.48% of total billed charges,77.4,90,,61.92,percent of total billed charges,90% of total billed charges,41.69,90,
DALIRESP TAB 250 MG,,,259,RC,,,outpatient,,,64,38.40,,38.4,60,,30.72,percent of total billed charges,60% of total billed charges,30.72,48,,24.576,percent of total billed charges,48% of total billed charges,32,50,,25.6,percent of total billed charges,50% of total billed charges,32,50,,25.6,percent of total billed charges,50% of total billed charges,32,50,,25.6,percent of total billed charges,50% of total billed charges,32,50,,25.6,percent of total billed charges,50% of total billed charges,44.8,70,,35.84,percent of total billed charges,70% of total billed charges,31.03,48.48,,24.824,percent of total billed charges,48.48% of total billed charges,31.03,48.48,,24.824,percent of total billed charges,48.48% of total billed charges,31.03,48.48,,24.824,percent of total billed charges,48.48% of total billed charges,44.8,70,,35.84,percent of total billed charges,70% of total billed charges,44.8,70,,35.84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,31.03,48.48,,24.824,percent of total billed charges,48.48% of total billed charges,57.6,90,,46.08,percent of total billed charges,90% of total billed charges,31.03,90,
CEFEPIME 2GM/D5 50 PREMIX,,,636,RC,J0692,HCPCS,outpatient,4,UN,144,86.40,,86.4,60,,69.12,percent of total billed charges,60% of total billed charges,69.12,48,,55.296,percent of total billed charges,48% of total billed charges,1.86,100,,,fee schedule,100% of bcbs custom fee schedule,1.86,100,,,fee schedule,100% of bcbs custom fee schedule,2.06,111,,,fee schedule,111% of bcbs custom fee schedule,72,50,,57.6,percent of total billed charges,50% of total billed charges,100.8,70,,80.64,percent of total billed charges,70% of total billed charges,69.81,48.48,,55.848,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,69.81,48.48,,55.848,percent of total billed charges,48.48% of total billed charges,100.8,70,,80.64,percent of total billed charges,70% of total billed charges,100.8,70,,80.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,69.81,48.48,,55.848,percent of total billed charges,48.48% of total billed charges,129.6,90,,103.68,percent of total billed charges,90% of total billed charges,48.48,129.6,
THERMOTABS 100 CT,,,259,RC,,,outpatient,,,25,15.00,,15,60,,12,percent of total billed charges,60% of total billed charges,12,48,,9.6,percent of total billed charges,48% of total billed charges,12.5,50,,10,percent of total billed charges,50% of total billed charges,12.5,50,,10,percent of total billed charges,50% of total billed charges,12.5,50,,10,percent of total billed charges,50% of total billed charges,12.5,50,,10,percent of total billed charges,50% of total billed charges,17.5,70,,14,percent of total billed charges,70% of total billed charges,12.12,48.48,,9.696,percent of total billed charges,48.48% of total billed charges,12.12,48.48,,9.696,percent of total billed charges,48.48% of total billed charges,12.12,48.48,,9.696,percent of total billed charges,48.48% of total billed charges,17.5,70,,14,percent of total billed charges,70% of total billed charges,17.5,70,,14,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,12.12,48.48,,9.696,percent of total billed charges,48.48% of total billed charges,22.5,90,,18,percent of total billed charges,90% of total billed charges,12.12,90,
VANCOMYCIN IVPB 1 GM PREMIX,,,636,RC,J3370,HCPCS,outpatient,2,UN,77,46.20,,46.2,60,,36.96,percent of total billed charges,60% of total billed charges,36.96,48,,29.568,percent of total billed charges,48% of total billed charges,3.05,100,,,fee schedule,100% of bcbs custom fee schedule,3.05,100,,,fee schedule,100% of bcbs custom fee schedule,3.39,111,,,fee schedule,111% of bcbs custom fee schedule,38.5,50,,30.8,percent of total billed charges,50% of total billed charges,53.9,70,,43.12,percent of total billed charges,70% of total billed charges,37.33,48.48,,29.864,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,37.33,48.48,,29.864,percent of total billed charges,48.48% of total billed charges,53.9,70,,43.12,percent of total billed charges,70% of total billed charges,53.9,70,,43.12,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,37.33,48.48,,29.864,percent of total billed charges,48.48% of total billed charges,69.3,90,,55.44,percent of total billed charges,90% of total billed charges,37.33,90,
VANCOMYCIN IVPB 1.5 GM PREMIX,,,636,RC,J3370,HCPCS,outpatient,,,111,66.60,,66.6,60,,53.28,percent of total billed charges,60% of total billed charges,53.28,48,,42.624,percent of total billed charges,48% of total billed charges,3.05,100,,,fee schedule,100% of bcbs custom fee schedule,3.05,100,,,fee schedule,100% of bcbs custom fee schedule,3.39,111,,,fee schedule,111% of bcbs custom fee schedule,55.5,50,,44.4,percent of total billed charges,50% of total billed charges,77.7,70,,62.16,percent of total billed charges,70% of total billed charges,53.81,48.48,,43.048,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,53.81,48.48,,43.048,percent of total billed charges,48.48% of total billed charges,77.7,70,,62.16,percent of total billed charges,70% of total billed charges,77.7,70,,62.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,53.81,48.48,,43.048,percent of total billed charges,48.48% of total billed charges,99.9,90,,79.92,percent of total billed charges,90% of total billed charges,48.48,99.9,
PROLIA INJ 60 MG,,,636,RC,J0897,HCPCS,outpatient,60,UN,3899,2339.40,,2339.4,60,,1871.52,percent of total billed charges,60% of total billed charges,1871.52,48,,1497.216,percent of total billed charges,48% of total billed charges,20.85,100,,,fee schedule,100% of bcbs custom fee schedule,20.85,100,,,fee schedule,100% of bcbs custom fee schedule,23.14,111,,,fee schedule,111% of bcbs custom fee schedule,1949.5,50,,1559.6,percent of total billed charges,50% of total billed charges,2729.3,70,,2183.44,percent of total billed charges,70% of total billed charges,1890.24,48.48,,1512.192,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,1890.24,48.48,,1512.192,percent of total billed charges,48.48% of total billed charges,2729.3,70,,2183.44,percent of total billed charges,70% of total billed charges,2729.3,70,,2183.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,1890.24,48.48,,1512.192,percent of total billed charges,48.48% of total billed charges,3509.1,90,,2807.28,percent of total billed charges,90% of total billed charges,48.48,3509.1,
FLUOXETINE 10 MG TAB,,,259,RC,,,outpatient,,,17,10.20,,10.2,60,,8.16,percent of total billed charges,60% of total billed charges,8.16,48,,6.528,percent of total billed charges,48% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,11.9,70,,9.52,percent of total billed charges,70% of total billed charges,8.24,48.48,,6.592,percent of total billed charges,48.48% of total billed charges,8.24,48.48,,6.592,percent of total billed charges,48.48% of total billed charges,8.24,48.48,,6.592,percent of total billed charges,48.48% of total billed charges,11.9,70,,9.52,percent of total billed charges,70% of total billed charges,11.9,70,,9.52,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,8.24,48.48,,6.592,percent of total billed charges,48.48% of total billed charges,15.3,90,,12.24,percent of total billed charges,90% of total billed charges,8.24,90,
LET Gel (Pediactric),,,259,RC,,,outpatient,,,21,12.60,,12.6,60,,10.08,percent of total billed charges,60% of total billed charges,10.08,48,,8.064,percent of total billed charges,48% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,14.7,70,,11.76,percent of total billed charges,70% of total billed charges,10.18,48.48,,8.144,percent of total billed charges,48.48% of total billed charges,10.18,48.48,,8.144,percent of total billed charges,48.48% of total billed charges,10.18,48.48,,8.144,percent of total billed charges,48.48% of total billed charges,14.7,70,,11.76,percent of total billed charges,70% of total billed charges,14.7,70,,11.76,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,10.18,48.48,,8.144,percent of total billed charges,48.48% of total billed charges,18.9,90,,15.12,percent of total billed charges,90% of total billed charges,10.18,90,
LET Gel (Adult),,,259,RC,,,outpatient,,,21,12.60,,12.6,60,,10.08,percent of total billed charges,60% of total billed charges,10.08,48,,8.064,percent of total billed charges,48% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,14.7,70,,11.76,percent of total billed charges,70% of total billed charges,10.18,48.48,,8.144,percent of total billed charges,48.48% of total billed charges,10.18,48.48,,8.144,percent of total billed charges,48.48% of total billed charges,10.18,48.48,,8.144,percent of total billed charges,48.48% of total billed charges,14.7,70,,11.76,percent of total billed charges,70% of total billed charges,14.7,70,,11.76,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,10.18,48.48,,8.144,percent of total billed charges,48.48% of total billed charges,18.9,90,,15.12,percent of total billed charges,90% of total billed charges,10.18,90,
NEUT SOD BICARB INJ,,,250,RC,,,outpatient,,,17,10.20,,10.2,60,,8.16,percent of total billed charges,60% of total billed charges,8.16,48,,6.528,percent of total billed charges,48% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,11.9,70,,9.52,percent of total billed charges,70% of total billed charges,8.24,48.48,,6.592,percent of total billed charges,48.48% of total billed charges,8.24,48.48,,6.592,percent of total billed charges,48.48% of total billed charges,8.24,48.48,,6.592,percent of total billed charges,48.48% of total billed charges,11.9,70,,9.52,percent of total billed charges,70% of total billed charges,11.9,70,,9.52,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,8.24,48.48,,6.592,percent of total billed charges,48.48% of total billed charges,15.3,90,,12.24,percent of total billed charges,90% of total billed charges,8.24,90,
CLINIMIX E 5/20 2000 ML,,,636,RC,B4189,HCPCS,outpatient,1,UN,418,250.80,,250.8,60,,200.64,percent of total billed charges,60% of total billed charges,200.64,48,,160.512,percent of total billed charges,48% of total billed charges,135.04,100,,,fee schedule,100% of bcbs custom fee schedule,135.04,100,,,fee schedule,100% of bcbs custom fee schedule,149.89,111,,,fee schedule,111% of bcbs custom fee schedule,209,50,,167.2,percent of total billed charges,50% of total billed charges,292.6,70,,234.08,percent of total billed charges,70% of total billed charges,202.65,48.48,,162.12,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,202.65,48.48,,162.12,percent of total billed charges,48.48% of total billed charges,292.6,70,,234.08,percent of total billed charges,70% of total billed charges,292.6,70,,234.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,202.65,48.48,,162.12,percent of total billed charges,48.48% of total billed charges,376.2,90,,300.96,percent of total billed charges,90% of total billed charges,48.48,376.2,
CLINIMIX E 4.25/5 2000 ML,,,250,RC,,,outpatient,,,359,215.40,,215.4,60,,172.32,percent of total billed charges,60% of total billed charges,172.32,48,,137.856,percent of total billed charges,48% of total billed charges,179.5,50,,143.6,percent of total billed charges,50% of total billed charges,179.5,50,,143.6,percent of total billed charges,50% of total billed charges,179.5,50,,143.6,percent of total billed charges,50% of total billed charges,179.5,50,,143.6,percent of total billed charges,50% of total billed charges,251.3,70,,201.04,percent of total billed charges,70% of total billed charges,174.04,48.48,,139.232,percent of total billed charges,48.48% of total billed charges,174.04,48.48,,139.232,percent of total billed charges,48.48% of total billed charges,174.04,48.48,,139.232,percent of total billed charges,48.48% of total billed charges,251.3,70,,201.04,percent of total billed charges,70% of total billed charges,251.3,70,,201.04,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,174.04,48.48,,139.232,percent of total billed charges,48.48% of total billed charges,323.1,90,,258.48,percent of total billed charges,90% of total billed charges,48.48,323.1,
VANCOMYCIN IVPB 2500 MG,,,636,RC,J3370,HCPCS,outpatient,,,260,156.00,,156,60,,124.8,percent of total billed charges,60% of total billed charges,124.8,48,,99.84,percent of total billed charges,48% of total billed charges,3.05,100,,,fee schedule,100% of bcbs custom fee schedule,3.05,100,,,fee schedule,100% of bcbs custom fee schedule,3.39,111,,,fee schedule,111% of bcbs custom fee schedule,130,50,,104,percent of total billed charges,50% of total billed charges,182,70,,145.6,percent of total billed charges,70% of total billed charges,126.05,48.48,,100.84,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,126.05,48.48,,100.84,percent of total billed charges,48.48% of total billed charges,182,70,,145.6,percent of total billed charges,70% of total billed charges,182,70,,145.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,126.05,48.48,,100.84,percent of total billed charges,48.48% of total billed charges,234,90,,187.2,percent of total billed charges,90% of total billed charges,48.48,234,
ZERBAXA 1.5G  IVPB,,,636,RC,J0695,HCPCS,outpatient,20,UN,693,415.80,,415.8,60,,332.64,percent of total billed charges,60% of total billed charges,332.64,48,,266.112,percent of total billed charges,48% of total billed charges,7.14,100,,,fee schedule,100% of bcbs custom fee schedule,7.14,100,,,fee schedule,100% of bcbs custom fee schedule,7.93,111,,,fee schedule,111% of bcbs custom fee schedule,346.5,50,,277.2,percent of total billed charges,50% of total billed charges,485.1,70,,388.08,percent of total billed charges,70% of total billed charges,335.97,48.48,,268.776,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,335.97,48.48,,268.776,percent of total billed charges,48.48% of total billed charges,485.1,70,,388.08,percent of total billed charges,70% of total billed charges,485.1,70,,388.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,335.97,48.48,,268.776,percent of total billed charges,48.48% of total billed charges,623.7,90,,498.96,percent of total billed charges,90% of total billed charges,48.48,623.7,
TORSEMIDE TAB 100 MG,,,259,RC,,,outpatient,,,12,7.20,,7.2,60,,5.76,percent of total billed charges,60% of total billed charges,5.76,48,,4.608,percent of total billed charges,48% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,8.4,70,,6.72,percent of total billed charges,70% of total billed charges,5.82,48.48,,4.656,percent of total billed charges,48.48% of total billed charges,5.82,48.48,,4.656,percent of total billed charges,48.48% of total billed charges,5.82,48.48,,4.656,percent of total billed charges,48.48% of total billed charges,8.4,70,,6.72,percent of total billed charges,70% of total billed charges,8.4,70,,6.72,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,5.82,48.48,,4.656,percent of total billed charges,48.48% of total billed charges,10.8,90,,8.64,percent of total billed charges,90% of total billed charges,5.82,90,
ZERBAXA 750MG IVPB,,,636,RC,,,outpatient,,,602,361.20,,361.2,60,,288.96,percent of total billed charges,60% of total billed charges,288.96,48,,231.168,percent of total billed charges,48% of total billed charges,301,50,,240.8,percent of total billed charges,50% of total billed charges,301,50,,240.8,percent of total billed charges,50% of total billed charges,301,50,,240.8,percent of total billed charges,50% of total billed charges,301,50,,240.8,percent of total billed charges,50% of total billed charges,421.4,70,,337.12,percent of total billed charges,70% of total billed charges,291.85,48.48,,233.48,percent of total billed charges,48.48% of total billed charges,291.85,48.48,,233.48,percent of total billed charges,48.48% of total billed charges,291.85,48.48,,233.48,percent of total billed charges,48.48% of total billed charges,421.4,70,,337.12,percent of total billed charges,70% of total billed charges,421.4,70,,337.12,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,291.85,48.48,,233.48,percent of total billed charges,48.48% of total billed charges,541.8,90,,433.44,percent of total billed charges,90% of total billed charges,48.48,541.8,
ZERBAXA 3 G IVPB,,,636,RC,,,outpatient,,,602,361.20,,361.2,60,,288.96,percent of total billed charges,60% of total billed charges,288.96,48,,231.168,percent of total billed charges,48% of total billed charges,301,50,,240.8,percent of total billed charges,50% of total billed charges,301,50,,240.8,percent of total billed charges,50% of total billed charges,301,50,,240.8,percent of total billed charges,50% of total billed charges,301,50,,240.8,percent of total billed charges,50% of total billed charges,421.4,70,,337.12,percent of total billed charges,70% of total billed charges,291.85,48.48,,233.48,percent of total billed charges,48.48% of total billed charges,291.85,48.48,,233.48,percent of total billed charges,48.48% of total billed charges,291.85,48.48,,233.48,percent of total billed charges,48.48% of total billed charges,421.4,70,,337.12,percent of total billed charges,70% of total billed charges,421.4,70,,337.12,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,291.85,48.48,,233.48,percent of total billed charges,48.48% of total billed charges,541.8,90,,433.44,percent of total billed charges,90% of total billed charges,48.48,541.8,
VANCOMYCIN INJ 1.25 GM,,,636,RC,,,outpatient,,,97,58.20,,58.2,60,,46.56,percent of total billed charges,60% of total billed charges,46.56,48,,37.248,percent of total billed charges,48% of total billed charges,48.5,50,,38.8,percent of total billed charges,50% of total billed charges,48.5,50,,38.8,percent of total billed charges,50% of total billed charges,48.5,50,,38.8,percent of total billed charges,50% of total billed charges,48.5,50,,38.8,percent of total billed charges,50% of total billed charges,67.9,70,,54.32,percent of total billed charges,70% of total billed charges,47.03,48.48,,37.624,percent of total billed charges,48.48% of total billed charges,47.03,48.48,,37.624,percent of total billed charges,48.48% of total billed charges,47.03,48.48,,37.624,percent of total billed charges,48.48% of total billed charges,67.9,70,,54.32,percent of total billed charges,70% of total billed charges,67.9,70,,54.32,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,47.03,48.48,,37.624,percent of total billed charges,48.48% of total billed charges,87.3,90,,69.84,percent of total billed charges,90% of total billed charges,47.03,90,
ENOXAPARIN INJ 150 MG,,,636,RC,J1650,HCPCS,outpatient,1,UN,108,64.80,,64.8,60,,51.84,percent of total billed charges,60% of total billed charges,51.84,48,,41.472,percent of total billed charges,48% of total billed charges,0.76,100,,,fee schedule,100% of bcbs custom fee schedule,0.76,100,,,fee schedule,100% of bcbs custom fee schedule,0.84,111,,,fee schedule,111% of bcbs custom fee schedule,54,50,,43.2,percent of total billed charges,50% of total billed charges,75.6,70,,60.48,percent of total billed charges,70% of total billed charges,52.36,48.48,,41.888,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,52.36,48.48,,41.888,percent of total billed charges,48.48% of total billed charges,75.6,70,,60.48,percent of total billed charges,70% of total billed charges,75.6,70,,60.48,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,52.36,48.48,,41.888,percent of total billed charges,48.48% of total billed charges,97.2,90,,77.76,percent of total billed charges,90% of total billed charges,48.48,97.2,
NAFCILLIN INJ 2GM,,,636,RC,,,outpatient,,,105,63.00,,63,60,,50.4,percent of total billed charges,60% of total billed charges,50.4,48,,40.32,percent of total billed charges,48% of total billed charges,52.5,50,,42,percent of total billed charges,50% of total billed charges,52.5,50,,42,percent of total billed charges,50% of total billed charges,52.5,50,,42,percent of total billed charges,50% of total billed charges,52.5,50,,42,percent of total billed charges,50% of total billed charges,73.5,70,,58.8,percent of total billed charges,70% of total billed charges,50.9,48.48,,40.72,percent of total billed charges,48.48% of total billed charges,50.9,48.48,,40.72,percent of total billed charges,48.48% of total billed charges,50.9,48.48,,40.72,percent of total billed charges,48.48% of total billed charges,73.5,70,,58.8,percent of total billed charges,70% of total billed charges,73.5,70,,58.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,50.9,48.48,,40.72,percent of total billed charges,48.48% of total billed charges,94.5,90,,75.6,percent of total billed charges,90% of total billed charges,48.48,94.5,
SOD CHL HYPERTONIC 4 ML,,,250,RC,,,outpatient,,,28,16.80,,16.8,60,,13.44,percent of total billed charges,60% of total billed charges,13.44,48,,10.752,percent of total billed charges,48% of total billed charges,14,50,,11.2,percent of total billed charges,50% of total billed charges,14,50,,11.2,percent of total billed charges,50% of total billed charges,14,50,,11.2,percent of total billed charges,50% of total billed charges,14,50,,11.2,percent of total billed charges,50% of total billed charges,19.6,70,,15.68,percent of total billed charges,70% of total billed charges,13.57,48.48,,10.856,percent of total billed charges,48.48% of total billed charges,13.57,48.48,,10.856,percent of total billed charges,48.48% of total billed charges,13.57,48.48,,10.856,percent of total billed charges,48.48% of total billed charges,19.6,70,,15.68,percent of total billed charges,70% of total billed charges,19.6,70,,15.68,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,13.57,48.48,,10.856,percent of total billed charges,48.48% of total billed charges,25.2,90,,20.16,percent of total billed charges,90% of total billed charges,13.57,90,
POLYSPORIN OPTH OINT 1/2 OZ,,,259,RC,,,outpatient,1,UN,115,69.00,,69,60,,55.2,percent of total billed charges,60% of total billed charges,55.2,48,,44.16,percent of total billed charges,48% of total billed charges,57.5,50,,46,percent of total billed charges,50% of total billed charges,57.5,50,,46,percent of total billed charges,50% of total billed charges,57.5,50,,46,percent of total billed charges,50% of total billed charges,57.5,50,,46,percent of total billed charges,50% of total billed charges,80.5,70,,64.4,percent of total billed charges,70% of total billed charges,55.75,48.48,,44.6,percent of total billed charges,48.48% of total billed charges,55.75,48.48,,44.6,percent of total billed charges,48.48% of total billed charges,55.75,48.48,,44.6,percent of total billed charges,48.48% of total billed charges,80.5,70,,64.4,percent of total billed charges,70% of total billed charges,80.5,70,,64.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,55.75,48.48,,44.6,percent of total billed charges,48.48% of total billed charges,103.5,90,,82.8,percent of total billed charges,90% of total billed charges,48.48,103.5,
HERPECIN L LIP BALM,,,259,RC,,,outpatient,,,15,9.00,,9,60,,7.2,percent of total billed charges,60% of total billed charges,7.2,48,,5.76,percent of total billed charges,48% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,13.5,90,,10.8,percent of total billed charges,90% of total billed charges,7.27,90,
AZITHROMYCIN 600 MG TAB,,,259,RC,,,outpatient,,,75,45.00,,45,60,,36,percent of total billed charges,60% of total billed charges,36,48,,28.8,percent of total billed charges,48% of total billed charges,37.5,50,,30,percent of total billed charges,50% of total billed charges,37.5,50,,30,percent of total billed charges,50% of total billed charges,37.5,50,,30,percent of total billed charges,50% of total billed charges,37.5,50,,30,percent of total billed charges,50% of total billed charges,52.5,70,,42,percent of total billed charges,70% of total billed charges,36.36,48.48,,29.088,percent of total billed charges,48.48% of total billed charges,36.36,48.48,,29.088,percent of total billed charges,48.48% of total billed charges,36.36,48.48,,29.088,percent of total billed charges,48.48% of total billed charges,52.5,70,,42,percent of total billed charges,70% of total billed charges,52.5,70,,42,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,36.36,48.48,,29.088,percent of total billed charges,48.48% of total billed charges,67.5,90,,54,percent of total billed charges,90% of total billed charges,36.36,90,
FORTAZ VL 500 MG,,,636,RC,,,outpatient,,,33,19.80,,19.8,60,,15.84,percent of total billed charges,60% of total billed charges,15.84,48,,12.672,percent of total billed charges,48% of total billed charges,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,23.1,70,,18.48,percent of total billed charges,70% of total billed charges,16,48.48,,12.8,percent of total billed charges,48.48% of total billed charges,16,48.48,,12.8,percent of total billed charges,48.48% of total billed charges,16,48.48,,12.8,percent of total billed charges,48.48% of total billed charges,23.1,70,,18.48,percent of total billed charges,70% of total billed charges,23.1,70,,18.48,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,16,48.48,,12.8,percent of total billed charges,48.48% of total billed charges,29.7,90,,23.76,percent of total billed charges,90% of total billed charges,16,90,
SOLU MEDROL 1GM IVPB,43601522,CDM,636,RC,J2919,HCPCS,outpatient,200,UN,212,127.20,,127.2,60,,101.76,percent of total billed charges,60% of total billed charges,101.76,48,,81.408,percent of total billed charges,48% of total billed charges,106,50,,84.8,percent of total billed charges,50% of total billed charges,106,50,,84.8,percent of total billed charges,50% of total billed charges,106,50,,84.8,percent of total billed charges,50% of total billed charges,106,50,,84.8,percent of total billed charges,50% of total billed charges,148.4,70,,118.72,percent of total billed charges,70% of total billed charges,102.78,48.48,,82.224,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,102.78,48.48,,82.224,percent of total billed charges,48.48% of total billed charges,148.4,70,,118.72,percent of total billed charges,70% of total billed charges,148.4,70,,118.72,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,102.78,48.48,,82.224,percent of total billed charges,48.48% of total billed charges,190.8,90,,152.64,percent of total billed charges,90% of total billed charges,48.48,190.8,
SOLU MEDROL 250 MG IVPB,,,636,RC,,,outpatient,,,94,56.40,,56.4,60,,45.12,percent of total billed charges,60% of total billed charges,45.12,48,,36.096,percent of total billed charges,48% of total billed charges,47,50,,37.6,percent of total billed charges,50% of total billed charges,47,50,,37.6,percent of total billed charges,50% of total billed charges,47,50,,37.6,percent of total billed charges,50% of total billed charges,47,50,,37.6,percent of total billed charges,50% of total billed charges,65.8,70,,52.64,percent of total billed charges,70% of total billed charges,45.57,48.48,,36.456,percent of total billed charges,48.48% of total billed charges,45.57,48.48,,36.456,percent of total billed charges,48.48% of total billed charges,45.57,48.48,,36.456,percent of total billed charges,48.48% of total billed charges,65.8,70,,52.64,percent of total billed charges,70% of total billed charges,65.8,70,,52.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,45.57,48.48,,36.456,percent of total billed charges,48.48% of total billed charges,84.6,90,,67.68,percent of total billed charges,90% of total billed charges,45.57,90,
SOLU MEDROL 500 MG IVPB,,,636,RC,,,outpatient,,,197,118.20,,118.2,60,,94.56,percent of total billed charges,60% of total billed charges,94.56,48,,75.648,percent of total billed charges,48% of total billed charges,98.5,50,,78.8,percent of total billed charges,50% of total billed charges,98.5,50,,78.8,percent of total billed charges,50% of total billed charges,98.5,50,,78.8,percent of total billed charges,50% of total billed charges,98.5,50,,78.8,percent of total billed charges,50% of total billed charges,137.9,70,,110.32,percent of total billed charges,70% of total billed charges,95.51,48.48,,76.408,percent of total billed charges,48.48% of total billed charges,95.51,48.48,,76.408,percent of total billed charges,48.48% of total billed charges,95.51,48.48,,76.408,percent of total billed charges,48.48% of total billed charges,137.9,70,,110.32,percent of total billed charges,70% of total billed charges,137.9,70,,110.32,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,95.51,48.48,,76.408,percent of total billed charges,48.48% of total billed charges,177.3,90,,141.84,percent of total billed charges,90% of total billed charges,48.48,177.3,
DALBAVANCIN INJ 1125 MG,,,636,RC,,,outpatient,,,11382,6829.20,,6829.2,60,,5463.36,percent of total billed charges,60% of total billed charges,5463.36,48,,4370.688,percent of total billed charges,48% of total billed charges,5691,50,,4552.8,percent of total billed charges,50% of total billed charges,5691,50,,4552.8,percent of total billed charges,50% of total billed charges,5691,50,,4552.8,percent of total billed charges,50% of total billed charges,5691,50,,4552.8,percent of total billed charges,50% of total billed charges,7967.4,70,,6373.92,percent of total billed charges,70% of total billed charges,5517.99,48.48,,4414.392,percent of total billed charges,48.48% of total billed charges,5517.99,48.48,,4414.392,percent of total billed charges,48.48% of total billed charges,5517.99,48.48,,4414.392,percent of total billed charges,48.48% of total billed charges,7967.4,70,,6373.92,percent of total billed charges,70% of total billed charges,7967.4,70,,6373.92,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,5517.99,48.48,,4414.392,percent of total billed charges,48.48% of total billed charges,10243.8,90,,8195.04,percent of total billed charges,90% of total billed charges,48.48,10243.8,
UBRELVY 100 MG TAB,,,259,RC,J8499,HCPCS,outpatient,1,UN,429,257.40,,257.4,60,,205.92,percent of total billed charges,60% of total billed charges,205.92,48,,164.736,percent of total billed charges,48% of total billed charges,214.5,50,,171.6,percent of total billed charges,50% of total billed charges,214.5,50,,171.6,percent of total billed charges,50% of total billed charges,214.5,50,,171.6,percent of total billed charges,50% of total billed charges,214.5,50,,171.6,percent of total billed charges,50% of total billed charges,300.3,70,,240.24,percent of total billed charges,70% of total billed charges,207.98,48.48,,166.384,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,207.98,48.48,,166.384,percent of total billed charges,48.48% of total billed charges,300.3,70,,240.24,percent of total billed charges,70% of total billed charges,300.3,70,,240.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,207.98,48.48,,166.384,percent of total billed charges,48.48% of total billed charges,386.1,90,,308.88,percent of total billed charges,90% of total billed charges,48.48,386.1,
MYXREDLIN [INSULIN DRIP],,,636,RC,J1815,HCPCS,outpatient,1,UN,168,100.80,,100.8,60,,80.64,percent of total billed charges,60% of total billed charges,80.64,48,,64.512,percent of total billed charges,48% of total billed charges,0.96,100,,,fee schedule,100% of bcbs custom fee schedule,0.96,100,,,fee schedule,100% of bcbs custom fee schedule,1.07,111,,,fee schedule,111% of bcbs custom fee schedule,84,50,,67.2,percent of total billed charges,50% of total billed charges,117.6,70,,94.08,percent of total billed charges,70% of total billed charges,81.45,48.48,,65.16,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,81.45,48.48,,65.16,percent of total billed charges,48.48% of total billed charges,117.6,70,,94.08,percent of total billed charges,70% of total billed charges,117.6,70,,94.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,81.45,48.48,,65.16,percent of total billed charges,48.48% of total billed charges,151.2,90,,120.96,percent of total billed charges,90% of total billed charges,48.48,151.2,
TRINTELLEX 20MG TAB,,,259,RC,,,outpatient,,,68,40.80,,40.8,60,,32.64,percent of total billed charges,60% of total billed charges,32.64,48,,26.112,percent of total billed charges,48% of total billed charges,34,50,,27.2,percent of total billed charges,50% of total billed charges,34,50,,27.2,percent of total billed charges,50% of total billed charges,34,50,,27.2,percent of total billed charges,50% of total billed charges,34,50,,27.2,percent of total billed charges,50% of total billed charges,47.6,70,,38.08,percent of total billed charges,70% of total billed charges,32.97,48.48,,26.376,percent of total billed charges,48.48% of total billed charges,32.97,48.48,,26.376,percent of total billed charges,48.48% of total billed charges,32.97,48.48,,26.376,percent of total billed charges,48.48% of total billed charges,47.6,70,,38.08,percent of total billed charges,70% of total billed charges,47.6,70,,38.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,32.97,48.48,,26.376,percent of total billed charges,48.48% of total billed charges,61.2,90,,48.96,percent of total billed charges,90% of total billed charges,32.97,90,
TRINTELLEX 10MG TAB,,,259,RC,,,outpatient,,,68,40.80,,40.8,60,,32.64,percent of total billed charges,60% of total billed charges,32.64,48,,26.112,percent of total billed charges,48% of total billed charges,34,50,,27.2,percent of total billed charges,50% of total billed charges,34,50,,27.2,percent of total billed charges,50% of total billed charges,34,50,,27.2,percent of total billed charges,50% of total billed charges,34,50,,27.2,percent of total billed charges,50% of total billed charges,47.6,70,,38.08,percent of total billed charges,70% of total billed charges,32.97,48.48,,26.376,percent of total billed charges,48.48% of total billed charges,32.97,48.48,,26.376,percent of total billed charges,48.48% of total billed charges,32.97,48.48,,26.376,percent of total billed charges,48.48% of total billed charges,47.6,70,,38.08,percent of total billed charges,70% of total billed charges,47.6,70,,38.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,32.97,48.48,,26.376,percent of total billed charges,48.48% of total billed charges,61.2,90,,48.96,percent of total billed charges,90% of total billed charges,32.97,90,
DIPRIVAN INJ 1000MG/100 ML,,,636,RC,J2704,HCPCS,outpatient,1,UN,150,90.00,,90,60,,72,percent of total billed charges,60% of total billed charges,72,48,,57.6,percent of total billed charges,48% of total billed charges,0.12,100,,,fee schedule,100% of bcbs custom fee schedule,0.12,100,,,fee schedule,100% of bcbs custom fee schedule,0.13,111,,,fee schedule,111% of bcbs custom fee schedule,75,50,,60,percent of total billed charges,50% of total billed charges,105,70,,84,percent of total billed charges,70% of total billed charges,72.72,48.48,,58.176,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,72.72,48.48,,58.176,percent of total billed charges,48.48% of total billed charges,105,70,,84,percent of total billed charges,70% of total billed charges,105,70,,84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,72.72,48.48,,58.176,percent of total billed charges,48.48% of total billed charges,135,90,,108,percent of total billed charges,90% of total billed charges,48.48,135,
SPACER FOR INHALER,,,250,RC,,,outpatient,,,34,20.40,,20.4,60,,16.32,percent of total billed charges,60% of total billed charges,16.32,48,,13.056,percent of total billed charges,48% of total billed charges,17,50,,13.6,percent of total billed charges,50% of total billed charges,17,50,,13.6,percent of total billed charges,50% of total billed charges,17,50,,13.6,percent of total billed charges,50% of total billed charges,17,50,,13.6,percent of total billed charges,50% of total billed charges,23.8,70,,19.04,percent of total billed charges,70% of total billed charges,16.48,48.48,,13.184,percent of total billed charges,48.48% of total billed charges,16.48,48.48,,13.184,percent of total billed charges,48.48% of total billed charges,16.48,48.48,,13.184,percent of total billed charges,48.48% of total billed charges,23.8,70,,19.04,percent of total billed charges,70% of total billed charges,23.8,70,,19.04,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,16.48,48.48,,13.184,percent of total billed charges,48.48% of total billed charges,30.6,90,,24.48,percent of total billed charges,90% of total billed charges,16.48,90,
STRATTERA CAP 25 MG,,,259,RC,,,outpatient,,,17,10.20,,10.2,60,,8.16,percent of total billed charges,60% of total billed charges,8.16,48,,6.528,percent of total billed charges,48% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,11.9,70,,9.52,percent of total billed charges,70% of total billed charges,8.24,48.48,,6.592,percent of total billed charges,48.48% of total billed charges,8.24,48.48,,6.592,percent of total billed charges,48.48% of total billed charges,8.24,48.48,,6.592,percent of total billed charges,48.48% of total billed charges,11.9,70,,9.52,percent of total billed charges,70% of total billed charges,11.9,70,,9.52,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,8.24,48.48,,6.592,percent of total billed charges,48.48% of total billed charges,15.3,90,,12.24,percent of total billed charges,90% of total billed charges,8.24,90,
ABILIFY TAB [2 MG],,,259,RC,,,outpatient,,,123,73.80,,73.8,60,,59.04,percent of total billed charges,60% of total billed charges,59.04,48,,47.232,percent of total billed charges,48% of total billed charges,61.5,50,,49.2,percent of total billed charges,50% of total billed charges,61.5,50,,49.2,percent of total billed charges,50% of total billed charges,61.5,50,,49.2,percent of total billed charges,50% of total billed charges,61.5,50,,49.2,percent of total billed charges,50% of total billed charges,86.1,70,,68.88,percent of total billed charges,70% of total billed charges,59.63,48.48,,47.704,percent of total billed charges,48.48% of total billed charges,59.63,48.48,,47.704,percent of total billed charges,48.48% of total billed charges,59.63,48.48,,47.704,percent of total billed charges,48.48% of total billed charges,86.1,70,,68.88,percent of total billed charges,70% of total billed charges,86.1,70,,68.88,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,59.63,48.48,,47.704,percent of total billed charges,48.48% of total billed charges,110.7,90,,88.56,percent of total billed charges,90% of total billed charges,48.48,110.7,
RITUXIMAB IVPB 700 MG,,,636,RC,,,outpatient,,,13256,7953.60,,7953.6,60,,6362.88,percent of total billed charges,60% of total billed charges,6362.88,48,,5090.304,percent of total billed charges,48% of total billed charges,6628,50,,5302.4,percent of total billed charges,50% of total billed charges,6628,50,,5302.4,percent of total billed charges,50% of total billed charges,6628,50,,5302.4,percent of total billed charges,50% of total billed charges,6628,50,,5302.4,percent of total billed charges,50% of total billed charges,9279.2,70,,7423.36,percent of total billed charges,70% of total billed charges,6426.51,48.48,,5141.208,percent of total billed charges,48.48% of total billed charges,6426.51,48.48,,5141.208,percent of total billed charges,48.48% of total billed charges,6426.51,48.48,,5141.208,percent of total billed charges,48.48% of total billed charges,9279.2,70,,7423.36,percent of total billed charges,70% of total billed charges,9279.2,70,,7423.36,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,6426.51,48.48,,5141.208,percent of total billed charges,48.48% of total billed charges,11930.4,90,,9544.32,percent of total billed charges,90% of total billed charges,48.48,11930.4,
OPCON-A OPTH DROPS,,,259,RC,,,outpatient,,,24,14.40,,14.4,60,,11.52,percent of total billed charges,60% of total billed charges,11.52,48,,9.216,percent of total billed charges,48% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,21.6,90,,17.28,percent of total billed charges,90% of total billed charges,11.64,90,
DEXILANT [30 MG],,,259,RC,,,outpatient,,,50,30.00,,30,60,,24,percent of total billed charges,60% of total billed charges,24,48,,19.2,percent of total billed charges,48% of total billed charges,25,50,,20,percent of total billed charges,50% of total billed charges,25,50,,20,percent of total billed charges,50% of total billed charges,25,50,,20,percent of total billed charges,50% of total billed charges,25,50,,20,percent of total billed charges,50% of total billed charges,35,70,,28,percent of total billed charges,70% of total billed charges,24.24,48.48,,19.392,percent of total billed charges,48.48% of total billed charges,24.24,48.48,,19.392,percent of total billed charges,48.48% of total billed charges,24.24,48.48,,19.392,percent of total billed charges,48.48% of total billed charges,35,70,,28,percent of total billed charges,70% of total billed charges,35,70,,28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,24.24,48.48,,19.392,percent of total billed charges,48.48% of total billed charges,45,90,,36,percent of total billed charges,90% of total billed charges,24.24,90,
MORPHINE INJ 2 MG,,,250,RC,,,outpatient,,,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
PROLENSA OPTH .07%,,,259,RC,,,outpatient,,,1439,863.40,,863.4,60,,690.72,percent of total billed charges,60% of total billed charges,690.72,48,,552.576,percent of total billed charges,48% of total billed charges,719.5,50,,575.6,percent of total billed charges,50% of total billed charges,719.5,50,,575.6,percent of total billed charges,50% of total billed charges,719.5,50,,575.6,percent of total billed charges,50% of total billed charges,719.5,50,,575.6,percent of total billed charges,50% of total billed charges,1007.3,70,,805.84,percent of total billed charges,70% of total billed charges,697.63,48.48,,558.104,percent of total billed charges,48.48% of total billed charges,697.63,48.48,,558.104,percent of total billed charges,48.48% of total billed charges,697.63,48.48,,558.104,percent of total billed charges,48.48% of total billed charges,1007.3,70,,805.84,percent of total billed charges,70% of total billed charges,1007.3,70,,805.84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,697.63,48.48,,558.104,percent of total billed charges,48.48% of total billed charges,1295.1,90,,1036.08,percent of total billed charges,90% of total billed charges,48.48,1295.1,
NYSTATIN/TRIAMCIN CREAM 60 OZ,,,259,RC,,,outpatient,,,455,273.00,,273,60,,218.4,percent of total billed charges,60% of total billed charges,218.4,48,,174.72,percent of total billed charges,48% of total billed charges,227.5,50,,182,percent of total billed charges,50% of total billed charges,227.5,50,,182,percent of total billed charges,50% of total billed charges,227.5,50,,182,percent of total billed charges,50% of total billed charges,227.5,50,,182,percent of total billed charges,50% of total billed charges,318.5,70,,254.8,percent of total billed charges,70% of total billed charges,220.58,48.48,,176.464,percent of total billed charges,48.48% of total billed charges,220.58,48.48,,176.464,percent of total billed charges,48.48% of total billed charges,220.58,48.48,,176.464,percent of total billed charges,48.48% of total billed charges,318.5,70,,254.8,percent of total billed charges,70% of total billed charges,318.5,70,,254.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,220.58,48.48,,176.464,percent of total billed charges,48.48% of total billed charges,409.5,90,,327.6,percent of total billed charges,90% of total billed charges,48.48,409.5,
TRESIBA INSULIN INJ,,,250,RC,,,outpatient,,,163,97.80,,97.8,60,,78.24,percent of total billed charges,60% of total billed charges,78.24,48,,62.592,percent of total billed charges,48% of total billed charges,81.5,50,,65.2,percent of total billed charges,50% of total billed charges,81.5,50,,65.2,percent of total billed charges,50% of total billed charges,81.5,50,,65.2,percent of total billed charges,50% of total billed charges,81.5,50,,65.2,percent of total billed charges,50% of total billed charges,114.1,70,,91.28,percent of total billed charges,70% of total billed charges,79.02,48.48,,63.216,percent of total billed charges,48.48% of total billed charges,79.02,48.48,,63.216,percent of total billed charges,48.48% of total billed charges,79.02,48.48,,63.216,percent of total billed charges,48.48% of total billed charges,114.1,70,,91.28,percent of total billed charges,70% of total billed charges,114.1,70,,91.28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,79.02,48.48,,63.216,percent of total billed charges,48.48% of total billed charges,146.7,90,,117.36,percent of total billed charges,90% of total billed charges,48.48,146.7,
ACETAZOLAMIDE INJ 500 MG,,,636,RC,,,outpatient,,,211,126.60,,126.6,60,,101.28,percent of total billed charges,60% of total billed charges,101.28,48,,81.024,percent of total billed charges,48% of total billed charges,105.5,50,,84.4,percent of total billed charges,50% of total billed charges,105.5,50,,84.4,percent of total billed charges,50% of total billed charges,105.5,50,,84.4,percent of total billed charges,50% of total billed charges,105.5,50,,84.4,percent of total billed charges,50% of total billed charges,147.7,70,,118.16,percent of total billed charges,70% of total billed charges,102.29,48.48,,81.832,percent of total billed charges,48.48% of total billed charges,102.29,48.48,,81.832,percent of total billed charges,48.48% of total billed charges,102.29,48.48,,81.832,percent of total billed charges,48.48% of total billed charges,147.7,70,,118.16,percent of total billed charges,70% of total billed charges,147.7,70,,118.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,102.29,48.48,,81.832,percent of total billed charges,48.48% of total billed charges,189.9,90,,151.92,percent of total billed charges,90% of total billed charges,48.48,189.9,
VICKS VAPO RUB 4 OZ,,,257,RC,,,outpatient,,,10,6.00,,6,60,,4.8,percent of total billed charges,60% of total billed charges,4.8,48,,3.84,percent of total billed charges,48% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,7,70,,5.6,percent of total billed charges,70% of total billed charges,4.85,48.48,,3.88,percent of total billed charges,48.48% of total billed charges,4.85,48.48,,3.88,percent of total billed charges,48.48% of total billed charges,4.85,48.48,,3.88,percent of total billed charges,48.48% of total billed charges,7,70,,5.6,percent of total billed charges,70% of total billed charges,7,70,,5.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,4.85,48.48,,3.88,percent of total billed charges,48.48% of total billed charges,9,90,,7.2,percent of total billed charges,90% of total billed charges,4.85,90,
FLUOXETINE SOL 20MG/5ML,,,259,RC,,,outpatient,,,29,17.40,,17.4,60,,13.92,percent of total billed charges,60% of total billed charges,13.92,48,,11.136,percent of total billed charges,48% of total billed charges,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,20.3,70,,16.24,percent of total billed charges,70% of total billed charges,14.06,48.48,,11.248,percent of total billed charges,48.48% of total billed charges,14.06,48.48,,11.248,percent of total billed charges,48.48% of total billed charges,14.06,48.48,,11.248,percent of total billed charges,48.48% of total billed charges,20.3,70,,16.24,percent of total billed charges,70% of total billed charges,20.3,70,,16.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,14.06,48.48,,11.248,percent of total billed charges,48.48% of total billed charges,26.1,90,,20.88,percent of total billed charges,90% of total billed charges,14.06,90,
VANCOMYCIN IVPB 1.25 GM PREMIX,,,636,RC,J3370,HCPCS,outpatient,3,UN,92.01,55.21,,55.21,60,,44.168,percent of total billed charges,60% of total billed charges,44.16,48,,35.328,percent of total billed charges,48% of total billed charges,3.05,100,,,fee schedule,100% of bcbs custom fee schedule,3.05,100,,,fee schedule,100% of bcbs custom fee schedule,3.39,111,,,fee schedule,111% of bcbs custom fee schedule,46.01,50,,36.808,percent of total billed charges,50% of total billed charges,64.41,70,,51.528,percent of total billed charges,70% of total billed charges,44.61,48.48,,35.688,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,44.61,48.48,,35.688,percent of total billed charges,48.48% of total billed charges,64.41,70,,51.528,percent of total billed charges,70% of total billed charges,64.41,70,,51.528,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,44.61,48.48,,35.688,percent of total billed charges,48.48% of total billed charges,82.81,90,,66.248,percent of total billed charges,90% of total billed charges,44.61,90,
JARDIANCE 25 MG TAB,,,259,RC,,,outpatient,,,88,52.80,,52.8,60,,42.24,percent of total billed charges,60% of total billed charges,42.24,48,,33.792,percent of total billed charges,48% of total billed charges,44,50,,35.2,percent of total billed charges,50% of total billed charges,44,50,,35.2,percent of total billed charges,50% of total billed charges,44,50,,35.2,percent of total billed charges,50% of total billed charges,44,50,,35.2,percent of total billed charges,50% of total billed charges,61.6,70,,49.28,percent of total billed charges,70% of total billed charges,42.66,48.48,,34.128,percent of total billed charges,48.48% of total billed charges,42.66,48.48,,34.128,percent of total billed charges,48.48% of total billed charges,42.66,48.48,,34.128,percent of total billed charges,48.48% of total billed charges,61.6,70,,49.28,percent of total billed charges,70% of total billed charges,61.6,70,,49.28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,42.66,48.48,,34.128,percent of total billed charges,48.48% of total billed charges,79.2,90,,63.36,percent of total billed charges,90% of total billed charges,42.66,90,
TIGECYCLINE INJ 50 MG,,,636,RC,J3243,HCPCS,outpatient,1,UN,480,288.00,,288,60,,230.4,percent of total billed charges,60% of total billed charges,230.4,48,,184.32,percent of total billed charges,48% of total billed charges,1.52,100,,,fee schedule,100% of bcbs custom fee schedule,1.52,100,,,fee schedule,100% of bcbs custom fee schedule,1.69,111,,,fee schedule,111% of bcbs custom fee schedule,240,50,,192,percent of total billed charges,50% of total billed charges,336,70,,268.8,percent of total billed charges,70% of total billed charges,232.7,48.48,,186.16,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,232.7,48.48,,186.16,percent of total billed charges,48.48% of total billed charges,336,70,,268.8,percent of total billed charges,70% of total billed charges,336,70,,268.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,232.7,48.48,,186.16,percent of total billed charges,48.48% of total billed charges,432,90,,345.6,percent of total billed charges,90% of total billed charges,48.48,432,
TIGECYCLINE INJ 50 MG,,,636,RC,J3243,HCPCS,outpatient,1,UN,480,288.00,,288,60,,230.4,percent of total billed charges,60% of total billed charges,230.4,48,,184.32,percent of total billed charges,48% of total billed charges,1.52,100,,,fee schedule,100% of bcbs custom fee schedule,1.52,100,,,fee schedule,100% of bcbs custom fee schedule,1.69,111,,,fee schedule,111% of bcbs custom fee schedule,240,50,,192,percent of total billed charges,50% of total billed charges,336,70,,268.8,percent of total billed charges,70% of total billed charges,232.7,48.48,,186.16,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,232.7,48.48,,186.16,percent of total billed charges,48.48% of total billed charges,336,70,,268.8,percent of total billed charges,70% of total billed charges,336,70,,268.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,232.7,48.48,,186.16,percent of total billed charges,48.48% of total billed charges,432,90,,345.6,percent of total billed charges,90% of total billed charges,48.48,432,
SILDENAFIL TAB 20 MG,,,259,RC,,,outpatient,,,66,39.60,,39.6,60,,31.68,percent of total billed charges,60% of total billed charges,31.68,48,,25.344,percent of total billed charges,48% of total billed charges,33,50,,26.4,percent of total billed charges,50% of total billed charges,33,50,,26.4,percent of total billed charges,50% of total billed charges,33,50,,26.4,percent of total billed charges,50% of total billed charges,33,50,,26.4,percent of total billed charges,50% of total billed charges,46.2,70,,36.96,percent of total billed charges,70% of total billed charges,32,48.48,,25.6,percent of total billed charges,48.48% of total billed charges,32,48.48,,25.6,percent of total billed charges,48.48% of total billed charges,32,48.48,,25.6,percent of total billed charges,48.48% of total billed charges,46.2,70,,36.96,percent of total billed charges,70% of total billed charges,46.2,70,,36.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,32,48.48,,25.6,percent of total billed charges,48.48% of total billed charges,59.4,90,,47.52,percent of total billed charges,90% of total billed charges,32,90,
REMDESIVIR IVPB 100 MG,,,636,RC,,,outpatient,,,2496,1497.60,,1497.6,60,,1198.08,percent of total billed charges,60% of total billed charges,1198.08,48,,958.464,percent of total billed charges,48% of total billed charges,1248,50,,998.4,percent of total billed charges,50% of total billed charges,1248,50,,998.4,percent of total billed charges,50% of total billed charges,1248,50,,998.4,percent of total billed charges,50% of total billed charges,1248,50,,998.4,percent of total billed charges,50% of total billed charges,1747.2,70,,1397.76,percent of total billed charges,70% of total billed charges,1210.06,48.48,,968.048,percent of total billed charges,48.48% of total billed charges,1210.06,48.48,,968.048,percent of total billed charges,48.48% of total billed charges,1210.06,48.48,,968.048,percent of total billed charges,48.48% of total billed charges,1747.2,70,,1397.76,percent of total billed charges,70% of total billed charges,1747.2,70,,1397.76,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,1210.06,48.48,,968.048,percent of total billed charges,48.48% of total billed charges,2246.4,90,,1797.12,percent of total billed charges,90% of total billed charges,48.48,2246.4,
REMDESIVIR IVPB 200 MG,,,636,RC,,,outpatient,,,4992,2995.20,,2995.2,60,,2396.16,percent of total billed charges,60% of total billed charges,2396.16,48,,1916.928,percent of total billed charges,48% of total billed charges,2496,50,,1996.8,percent of total billed charges,50% of total billed charges,2496,50,,1996.8,percent of total billed charges,50% of total billed charges,2496,50,,1996.8,percent of total billed charges,50% of total billed charges,2496,50,,1996.8,percent of total billed charges,50% of total billed charges,3494.4,70,,2795.52,percent of total billed charges,70% of total billed charges,2420.12,48.48,,1936.096,percent of total billed charges,48.48% of total billed charges,2420.12,48.48,,1936.096,percent of total billed charges,48.48% of total billed charges,2420.12,48.48,,1936.096,percent of total billed charges,48.48% of total billed charges,3494.4,70,,2795.52,percent of total billed charges,70% of total billed charges,3494.4,70,,2795.52,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,2420.12,48.48,,1936.096,percent of total billed charges,48.48% of total billed charges,4492.8,90,,3594.24,percent of total billed charges,90% of total billed charges,48.48,4492.8,
MIDAZOLAM 50MG/NS 100ML IVPB,,,636,RC,J2250,HCPCS,outpatient,50,UN,34,20.40,,20.4,60,,16.32,percent of total billed charges,60% of total billed charges,16.32,48,,13.056,percent of total billed charges,48% of total billed charges,0.14,100,,,fee schedule,100% of bcbs custom fee schedule,0.14,100,,,fee schedule,100% of bcbs custom fee schedule,0.16,111,,,fee schedule,111% of bcbs custom fee schedule,17,50,,13.6,percent of total billed charges,50% of total billed charges,23.8,70,,19.04,percent of total billed charges,70% of total billed charges,16.48,48.48,,13.184,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,16.48,48.48,,13.184,percent of total billed charges,48.48% of total billed charges,23.8,70,,19.04,percent of total billed charges,70% of total billed charges,23.8,70,,19.04,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,16.48,48.48,,13.184,percent of total billed charges,48.48% of total billed charges,30.6,90,,24.48,percent of total billed charges,90% of total billed charges,16.48,90,
SOLIRIS IVPB 1200 MG,,,636,RC,J1300,HCPCS,outpatient,120,UN,521.8,313.08,,313.08,60,,250.464,percent of total billed charges,60% of total billed charges,250.46,48,,200.368,percent of total billed charges,48% of total billed charges,230.48,100,,,fee schedule,100% of bcbs custom fee schedule,230.48,100,,,fee schedule,100% of bcbs custom fee schedule,255.83,111,,,fee schedule,111% of bcbs custom fee schedule,260.9,50,,208.72,percent of total billed charges,50% of total billed charges,365.26,70,,292.208,percent of total billed charges,70% of total billed charges,252.97,48.48,,202.376,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,252.97,48.48,,202.376,percent of total billed charges,48.48% of total billed charges,365.26,70,,292.208,percent of total billed charges,70% of total billed charges,365.26,70,,292.208,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,252.97,48.48,,202.376,percent of total billed charges,48.48% of total billed charges,469.62,90,,375.696,percent of total billed charges,90% of total billed charges,48.48,469.62,
ENOXAPARIN INJ 60 MG,,,636,RC,J1650,HCPCS,outpatient,1,UN,44,26.40,,26.4,60,,21.12,percent of total billed charges,60% of total billed charges,21.12,48,,16.896,percent of total billed charges,48% of total billed charges,0.76,100,,,fee schedule,100% of bcbs custom fee schedule,0.76,100,,,fee schedule,100% of bcbs custom fee schedule,0.84,111,,,fee schedule,111% of bcbs custom fee schedule,22,50,,17.6,percent of total billed charges,50% of total billed charges,30.8,70,,24.64,percent of total billed charges,70% of total billed charges,21.33,48.48,,17.064,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,21.33,48.48,,17.064,percent of total billed charges,48.48% of total billed charges,30.8,70,,24.64,percent of total billed charges,70% of total billed charges,30.8,70,,24.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,21.33,48.48,,17.064,percent of total billed charges,48.48% of total billed charges,39.6,90,,31.68,percent of total billed charges,90% of total billed charges,21.33,90,
VANCOMYCIN IVPB 1.75 GM PREMIX,,,636,RC,J3370,HCPCS,outpatient,1,UN,125,75.00,,75,60,,60,percent of total billed charges,60% of total billed charges,60,48,,48,percent of total billed charges,48% of total billed charges,3.05,100,,,fee schedule,100% of bcbs custom fee schedule,3.05,100,,,fee schedule,100% of bcbs custom fee schedule,3.39,111,,,fee schedule,111% of bcbs custom fee schedule,62.5,50,,50,percent of total billed charges,50% of total billed charges,87.5,70,,70,percent of total billed charges,70% of total billed charges,60.6,48.48,,48.48,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,60.6,48.48,,48.48,percent of total billed charges,48.48% of total billed charges,87.5,70,,70,percent of total billed charges,70% of total billed charges,87.5,70,,70,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,60.6,48.48,,48.48,percent of total billed charges,48.48% of total billed charges,112.5,90,,90,percent of total billed charges,90% of total billed charges,48.48,112.5,
CEFTRIAXONE 1 GM PREMIX,43601503,CDM,636,RC,J0696,HCPCS,outpatient,4,UN,95,57.00,,57,60,,45.6,percent of total billed charges,60% of total billed charges,45.6,48,,36.48,percent of total billed charges,48% of total billed charges,0.69,100,,,fee schedule,100% of bcbs custom fee schedule,0.69,100,,,fee schedule,100% of bcbs custom fee schedule,0.77,111,,,fee schedule,111% of bcbs custom fee schedule,47.5,50,,38,percent of total billed charges,50% of total billed charges,66.5,70,,53.2,percent of total billed charges,70% of total billed charges,46.06,48.48,,36.848,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,46.06,48.48,,36.848,percent of total billed charges,48.48% of total billed charges,66.5,70,,53.2,percent of total billed charges,70% of total billed charges,66.5,70,,53.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,46.06,48.48,,36.848,percent of total billed charges,48.48% of total billed charges,85.5,90,,68.4,percent of total billed charges,90% of total billed charges,46.06,90,
VANCOMYCIN IVPB 750 MG PREMIX,,,636,RC,J3370,HCPCS,outpatient,,,58,34.80,,34.8,60,,27.84,percent of total billed charges,60% of total billed charges,27.84,48,,22.272,percent of total billed charges,48% of total billed charges,3.05,100,,,fee schedule,100% of bcbs custom fee schedule,3.05,100,,,fee schedule,100% of bcbs custom fee schedule,3.39,111,,,fee schedule,111% of bcbs custom fee schedule,29,50,,23.2,percent of total billed charges,50% of total billed charges,40.6,70,,32.48,percent of total billed charges,70% of total billed charges,28.12,48.48,,22.496,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,28.12,48.48,,22.496,percent of total billed charges,48.48% of total billed charges,40.6,70,,32.48,percent of total billed charges,70% of total billed charges,40.6,70,,32.48,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,28.12,48.48,,22.496,percent of total billed charges,48.48% of total billed charges,52.2,90,,41.76,percent of total billed charges,90% of total billed charges,28.12,90,
Bamlanivimab Administration,,,250,RC,M0239,HCPCS,outpatient,,,340.56,204.34,,204.34,60,,163.472,percent of total billed charges,60% of total billed charges,163.47,48,,130.776,percent of total billed charges,48% of total billed charges,310.75,100,,,fee schedule,100% of bcbs custom fee schedule,310.75,100,,,fee schedule,100% of bcbs custom fee schedule,344.93,111,,,fee schedule,111% of bcbs custom fee schedule,170.28,50,,136.224,percent of total billed charges,50% of total billed charges,238.39,70,,190.712,percent of total billed charges,70% of total billed charges,165.1,48.48,,132.08,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,165.1,48.48,,132.08,percent of total billed charges,48.48% of total billed charges,238.39,70,,190.712,percent of total billed charges,70% of total billed charges,238.39,70,,190.712,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,165.1,48.48,,132.08,percent of total billed charges,48.48% of total billed charges,306.5,90,,245.2,percent of total billed charges,90% of total billed charges,48.48,306.5,
CLINIMIX 4.25/D5 1000 ML,,,636,RC,,,outpatient,,,159,95.40,,95.4,60,,76.32,percent of total billed charges,60% of total billed charges,76.32,48,,61.056,percent of total billed charges,48% of total billed charges,79.5,50,,63.6,percent of total billed charges,50% of total billed charges,79.5,50,,63.6,percent of total billed charges,50% of total billed charges,79.5,50,,63.6,percent of total billed charges,50% of total billed charges,79.5,50,,63.6,percent of total billed charges,50% of total billed charges,111.3,70,,89.04,percent of total billed charges,70% of total billed charges,77.08,48.48,,61.664,percent of total billed charges,48.48% of total billed charges,77.08,48.48,,61.664,percent of total billed charges,48.48% of total billed charges,77.08,48.48,,61.664,percent of total billed charges,48.48% of total billed charges,111.3,70,,89.04,percent of total billed charges,70% of total billed charges,111.3,70,,89.04,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,77.08,48.48,,61.664,percent of total billed charges,48.48% of total billed charges,143.1,90,,114.48,percent of total billed charges,90% of total billed charges,48.48,143.1,
CLINIMIX 4.25/D5 2000 ML,,,636,RC,,,outpatient,,,312,187.20,,187.2,60,,149.76,percent of total billed charges,60% of total billed charges,149.76,48,,119.808,percent of total billed charges,48% of total billed charges,156,50,,124.8,percent of total billed charges,50% of total billed charges,156,50,,124.8,percent of total billed charges,50% of total billed charges,156,50,,124.8,percent of total billed charges,50% of total billed charges,156,50,,124.8,percent of total billed charges,50% of total billed charges,218.4,70,,174.72,percent of total billed charges,70% of total billed charges,151.26,48.48,,121.008,percent of total billed charges,48.48% of total billed charges,151.26,48.48,,121.008,percent of total billed charges,48.48% of total billed charges,151.26,48.48,,121.008,percent of total billed charges,48.48% of total billed charges,218.4,70,,174.72,percent of total billed charges,70% of total billed charges,218.4,70,,174.72,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,151.26,48.48,,121.008,percent of total billed charges,48.48% of total billed charges,280.8,90,,224.64,percent of total billed charges,90% of total billed charges,48.48,280.8,
DRONABINOL CAP [2.5 MG],,,259,RC,,,outpatient,,,22,13.20,,13.2,60,,10.56,percent of total billed charges,60% of total billed charges,10.56,48,,8.448,percent of total billed charges,48% of total billed charges,11,50,,8.8,percent of total billed charges,50% of total billed charges,11,50,,8.8,percent of total billed charges,50% of total billed charges,11,50,,8.8,percent of total billed charges,50% of total billed charges,11,50,,8.8,percent of total billed charges,50% of total billed charges,15.4,70,,12.32,percent of total billed charges,70% of total billed charges,10.67,48.48,,8.536,percent of total billed charges,48.48% of total billed charges,10.67,48.48,,8.536,percent of total billed charges,48.48% of total billed charges,10.67,48.48,,8.536,percent of total billed charges,48.48% of total billed charges,15.4,70,,12.32,percent of total billed charges,70% of total billed charges,15.4,70,,12.32,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,10.67,48.48,,8.536,percent of total billed charges,48.48% of total billed charges,19.8,90,,15.84,percent of total billed charges,90% of total billed charges,10.67,90,
GENTAMICIN 120 MG PREMIX IVPB,43601682,CDM,636,RC,J1580,HCPCS,outpatient,2,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,1.97,100,,,fee schedule,100% of bcbs custom fee schedule,1.97,100,,,fee schedule,100% of bcbs custom fee schedule,2.19,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
GUANFACINE ER [1 MG],,,259,RC,,,outpatient,,,42,25.20,,25.2,60,,20.16,percent of total billed charges,60% of total billed charges,20.16,48,,16.128,percent of total billed charges,48% of total billed charges,21,50,,16.8,percent of total billed charges,50% of total billed charges,21,50,,16.8,percent of total billed charges,50% of total billed charges,21,50,,16.8,percent of total billed charges,50% of total billed charges,21,50,,16.8,percent of total billed charges,50% of total billed charges,29.4,70,,23.52,percent of total billed charges,70% of total billed charges,20.36,48.48,,16.288,percent of total billed charges,48.48% of total billed charges,20.36,48.48,,16.288,percent of total billed charges,48.48% of total billed charges,20.36,48.48,,16.288,percent of total billed charges,48.48% of total billed charges,29.4,70,,23.52,percent of total billed charges,70% of total billed charges,29.4,70,,23.52,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,20.36,48.48,,16.288,percent of total billed charges,48.48% of total billed charges,37.8,90,,30.24,percent of total billed charges,90% of total billed charges,20.36,90,
CEFTRIAXONE 2 GM PREMIX,43601503,CDM,636,RC,J0696,HCPCS,outpatient,8,UN,126,75.60,,75.6,60,,60.48,percent of total billed charges,60% of total billed charges,60.48,48,,48.384,percent of total billed charges,48% of total billed charges,0.69,100,,,fee schedule,100% of bcbs custom fee schedule,0.69,100,,,fee schedule,100% of bcbs custom fee schedule,0.77,111,,,fee schedule,111% of bcbs custom fee schedule,63,50,,50.4,percent of total billed charges,50% of total billed charges,88.2,70,,70.56,percent of total billed charges,70% of total billed charges,61.08,48.48,,48.864,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,61.08,48.48,,48.864,percent of total billed charges,48.48% of total billed charges,88.2,70,,70.56,percent of total billed charges,70% of total billed charges,88.2,70,,70.56,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,61.08,48.48,,48.864,percent of total billed charges,48.48% of total billed charges,113.4,90,,90.72,percent of total billed charges,90% of total billed charges,48.48,113.4,
RITUXIMAB IVPB 500 MG,,,636,RC,,,outpatient,,,11275,6765.00,,6765,60,,5412,percent of total billed charges,60% of total billed charges,5412,48,,4329.6,percent of total billed charges,48% of total billed charges,5637.5,50,,4510,percent of total billed charges,50% of total billed charges,5637.5,50,,4510,percent of total billed charges,50% of total billed charges,5637.5,50,,4510,percent of total billed charges,50% of total billed charges,5637.5,50,,4510,percent of total billed charges,50% of total billed charges,7892.5,70,,6314,percent of total billed charges,70% of total billed charges,5466.12,48.48,,4372.896,percent of total billed charges,48.48% of total billed charges,5466.12,48.48,,4372.896,percent of total billed charges,48.48% of total billed charges,5466.12,48.48,,4372.896,percent of total billed charges,48.48% of total billed charges,7892.5,70,,6314,percent of total billed charges,70% of total billed charges,7892.5,70,,6314,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,5466.12,48.48,,4372.896,percent of total billed charges,48.48% of total billed charges,10147.5,90,,8118,percent of total billed charges,90% of total billed charges,48.48,10147.5,
OLUMIANT TAB 2 MG,,,259,RC,,,outpatient,,,318,190.80,,190.8,60,,152.64,percent of total billed charges,60% of total billed charges,152.64,48,,122.112,percent of total billed charges,48% of total billed charges,159,50,,127.2,percent of total billed charges,50% of total billed charges,159,50,,127.2,percent of total billed charges,50% of total billed charges,159,50,,127.2,percent of total billed charges,50% of total billed charges,159,50,,127.2,percent of total billed charges,50% of total billed charges,222.6,70,,178.08,percent of total billed charges,70% of total billed charges,154.17,48.48,,123.336,percent of total billed charges,48.48% of total billed charges,154.17,48.48,,123.336,percent of total billed charges,48.48% of total billed charges,154.17,48.48,,123.336,percent of total billed charges,48.48% of total billed charges,222.6,70,,178.08,percent of total billed charges,70% of total billed charges,222.6,70,,178.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,154.17,48.48,,123.336,percent of total billed charges,48.48% of total billed charges,286.2,90,,228.96,percent of total billed charges,90% of total billed charges,48.48,286.2,
MENQUADFI VACCINE,,,636,RC,90619,HCPCS,outpatient,1,UN,340,204.00,,204,60,,163.2,percent of total billed charges,60% of total billed charges,163.2,48,,130.56,percent of total billed charges,48% of total billed charges,151.94,100,,,fee schedule,100% of bcbs custom fee schedule,151.94,100,,,fee schedule,100% of bcbs custom fee schedule,168.65,111,,,fee schedule,111% of bcbs custom fee schedule,170,50,,136,percent of total billed charges,50% of total billed charges,238,70,,190.4,percent of total billed charges,70% of total billed charges,164.83,48.48,,131.864,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,164.83,48.48,,131.864,percent of total billed charges,48.48% of total billed charges,238,70,,190.4,percent of total billed charges,70% of total billed charges,238,70,,190.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,164.83,48.48,,131.864,percent of total billed charges,48.48% of total billed charges,306,90,,244.8,percent of total billed charges,90% of total billed charges,48.48,306,
"RETACRIT 20,000 IU",,,636,RC,,,outpatient,,,1059,635.40,,635.4,60,,508.32,percent of total billed charges,60% of total billed charges,508.32,48,,406.656,percent of total billed charges,48% of total billed charges,529.5,50,,423.6,percent of total billed charges,50% of total billed charges,529.5,50,,423.6,percent of total billed charges,50% of total billed charges,529.5,50,,423.6,percent of total billed charges,50% of total billed charges,529.5,50,,423.6,percent of total billed charges,50% of total billed charges,741.3,70,,593.04,percent of total billed charges,70% of total billed charges,513.4,48.48,,410.72,percent of total billed charges,48.48% of total billed charges,513.4,48.48,,410.72,percent of total billed charges,48.48% of total billed charges,513.4,48.48,,410.72,percent of total billed charges,48.48% of total billed charges,741.3,70,,593.04,percent of total billed charges,70% of total billed charges,741.3,70,,593.04,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,513.4,48.48,,410.72,percent of total billed charges,48.48% of total billed charges,953.1,90,,762.48,percent of total billed charges,90% of total billed charges,48.48,953.1,
INTRALIPID 20% 500 ML,,,250,RC,,,outpatient,,,130,78.00,,78,60,,62.4,percent of total billed charges,60% of total billed charges,62.4,48,,49.92,percent of total billed charges,48% of total billed charges,65,50,,52,percent of total billed charges,50% of total billed charges,65,50,,52,percent of total billed charges,50% of total billed charges,65,50,,52,percent of total billed charges,50% of total billed charges,65,50,,52,percent of total billed charges,50% of total billed charges,91,70,,72.8,percent of total billed charges,70% of total billed charges,63.02,48.48,,50.416,percent of total billed charges,48.48% of total billed charges,63.02,48.48,,50.416,percent of total billed charges,48.48% of total billed charges,63.02,48.48,,50.416,percent of total billed charges,48.48% of total billed charges,91,70,,72.8,percent of total billed charges,70% of total billed charges,91,70,,72.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,63.02,48.48,,50.416,percent of total billed charges,48.48% of total billed charges,117,90,,93.6,percent of total billed charges,90% of total billed charges,48.48,117,
BREVIBLOC (ESMOLOL) 250 ML,,,636,RC,,,outpatient,,,2245,1347.00,,1347,60,,1077.6,percent of total billed charges,60% of total billed charges,1077.6,48,,862.08,percent of total billed charges,48% of total billed charges,1122.5,50,,898,percent of total billed charges,50% of total billed charges,1122.5,50,,898,percent of total billed charges,50% of total billed charges,1122.5,50,,898,percent of total billed charges,50% of total billed charges,1122.5,50,,898,percent of total billed charges,50% of total billed charges,1571.5,70,,1257.2,percent of total billed charges,70% of total billed charges,1088.38,48.48,,870.704,percent of total billed charges,48.48% of total billed charges,1088.38,48.48,,870.704,percent of total billed charges,48.48% of total billed charges,1088.38,48.48,,870.704,percent of total billed charges,48.48% of total billed charges,1571.5,70,,1257.2,percent of total billed charges,70% of total billed charges,1571.5,70,,1257.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,1088.38,48.48,,870.704,percent of total billed charges,48.48% of total billed charges,2020.5,90,,1616.4,percent of total billed charges,90% of total billed charges,48.48,2020.5,
Remdesivir 200 mg (Outpatient),,,636,RC,,,outpatient,,,2080,1248.00,,1248,60,,998.4,percent of total billed charges,60% of total billed charges,998.4,48,,798.72,percent of total billed charges,48% of total billed charges,1040,50,,832,percent of total billed charges,50% of total billed charges,1040,50,,832,percent of total billed charges,50% of total billed charges,1040,50,,832,percent of total billed charges,50% of total billed charges,1040,50,,832,percent of total billed charges,50% of total billed charges,1456,70,,1164.8,percent of total billed charges,70% of total billed charges,1008.38,48.48,,806.704,percent of total billed charges,48.48% of total billed charges,1008.38,48.48,,806.704,percent of total billed charges,48.48% of total billed charges,1008.38,48.48,,806.704,percent of total billed charges,48.48% of total billed charges,1456,70,,1164.8,percent of total billed charges,70% of total billed charges,1456,70,,1164.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,1008.38,48.48,,806.704,percent of total billed charges,48.48% of total billed charges,1872,90,,1497.6,percent of total billed charges,90% of total billed charges,48.48,1872,
Remdesivir 100 mg (Outpatient),,,636,RC,,,outpatient,,,1040,624.00,,624,60,,499.2,percent of total billed charges,60% of total billed charges,499.2,48,,399.36,percent of total billed charges,48% of total billed charges,520,50,,416,percent of total billed charges,50% of total billed charges,520,50,,416,percent of total billed charges,50% of total billed charges,520,50,,416,percent of total billed charges,50% of total billed charges,520,50,,416,percent of total billed charges,50% of total billed charges,728,70,,582.4,percent of total billed charges,70% of total billed charges,504.19,48.48,,403.352,percent of total billed charges,48.48% of total billed charges,504.19,48.48,,403.352,percent of total billed charges,48.48% of total billed charges,504.19,48.48,,403.352,percent of total billed charges,48.48% of total billed charges,728,70,,582.4,percent of total billed charges,70% of total billed charges,728,70,,582.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,504.19,48.48,,403.352,percent of total billed charges,48.48% of total billed charges,936,90,,748.8,percent of total billed charges,90% of total billed charges,48.48,936,
THEOPH ER 300 MG,,,259,RC,,,outpatient,,,18,10.80,,10.8,60,,8.64,percent of total billed charges,60% of total billed charges,8.64,48,,6.912,percent of total billed charges,48% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,12.6,70,,10.08,percent of total billed charges,70% of total billed charges,8.73,48.48,,6.984,percent of total billed charges,48.48% of total billed charges,8.73,48.48,,6.984,percent of total billed charges,48.48% of total billed charges,8.73,48.48,,6.984,percent of total billed charges,48.48% of total billed charges,12.6,70,,10.08,percent of total billed charges,70% of total billed charges,12.6,70,,10.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,8.73,48.48,,6.984,percent of total billed charges,48.48% of total billed charges,16.2,90,,12.96,percent of total billed charges,90% of total billed charges,8.73,90,
IPRATROPIUM NASAL SPRAY,,,259,RC,,,outpatient,,,183,109.80,,109.8,60,,87.84,percent of total billed charges,60% of total billed charges,87.84,48,,70.272,percent of total billed charges,48% of total billed charges,91.5,50,,73.2,percent of total billed charges,50% of total billed charges,91.5,50,,73.2,percent of total billed charges,50% of total billed charges,91.5,50,,73.2,percent of total billed charges,50% of total billed charges,91.5,50,,73.2,percent of total billed charges,50% of total billed charges,128.1,70,,102.48,percent of total billed charges,70% of total billed charges,88.72,48.48,,70.976,percent of total billed charges,48.48% of total billed charges,88.72,48.48,,70.976,percent of total billed charges,48.48% of total billed charges,88.72,48.48,,70.976,percent of total billed charges,48.48% of total billed charges,128.1,70,,102.48,percent of total billed charges,70% of total billed charges,128.1,70,,102.48,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,88.72,48.48,,70.976,percent of total billed charges,48.48% of total billed charges,164.7,90,,131.76,percent of total billed charges,90% of total billed charges,48.48,164.7,
CEFAZOLIN 2GM,,,636,RC,,,outpatient,,,62,37.20,,37.2,60,,29.76,percent of total billed charges,60% of total billed charges,29.76,48,,23.808,percent of total billed charges,48% of total billed charges,31,50,,24.8,percent of total billed charges,50% of total billed charges,31,50,,24.8,percent of total billed charges,50% of total billed charges,31,50,,24.8,percent of total billed charges,50% of total billed charges,31,50,,24.8,percent of total billed charges,50% of total billed charges,43.4,70,,34.72,percent of total billed charges,70% of total billed charges,30.06,48.48,,24.048,percent of total billed charges,48.48% of total billed charges,30.06,48.48,,24.048,percent of total billed charges,48.48% of total billed charges,30.06,48.48,,24.048,percent of total billed charges,48.48% of total billed charges,43.4,70,,34.72,percent of total billed charges,70% of total billed charges,43.4,70,,34.72,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,30.06,48.48,,24.048,percent of total billed charges,48.48% of total billed charges,55.8,90,,44.64,percent of total billed charges,90% of total billed charges,30.06,90,
ENOXAPARIN INJ 120 MG,,,636,RC,J1650,HCPCS,outpatient,1,UN,87,52.20,,52.2,60,,41.76,percent of total billed charges,60% of total billed charges,41.76,48,,33.408,percent of total billed charges,48% of total billed charges,0.76,100,,,fee schedule,100% of bcbs custom fee schedule,0.76,100,,,fee schedule,100% of bcbs custom fee schedule,0.84,111,,,fee schedule,111% of bcbs custom fee schedule,43.5,50,,34.8,percent of total billed charges,50% of total billed charges,60.9,70,,48.72,percent of total billed charges,70% of total billed charges,42.18,48.48,,33.744,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,42.18,48.48,,33.744,percent of total billed charges,48.48% of total billed charges,60.9,70,,48.72,percent of total billed charges,70% of total billed charges,60.9,70,,48.72,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,42.18,48.48,,33.744,percent of total billed charges,48.48% of total billed charges,78.3,90,,62.64,percent of total billed charges,90% of total billed charges,42.18,90,
ALOGLIPTIN TAB (12.5 MG),,,259,RC,,,outpatient,,,32,19.20,,19.2,60,,15.36,percent of total billed charges,60% of total billed charges,15.36,48,,12.288,percent of total billed charges,48% of total billed charges,16,50,,12.8,percent of total billed charges,50% of total billed charges,16,50,,12.8,percent of total billed charges,50% of total billed charges,16,50,,12.8,percent of total billed charges,50% of total billed charges,16,50,,12.8,percent of total billed charges,50% of total billed charges,22.4,70,,17.92,percent of total billed charges,70% of total billed charges,15.51,48.48,,12.408,percent of total billed charges,48.48% of total billed charges,15.51,48.48,,12.408,percent of total billed charges,48.48% of total billed charges,15.51,48.48,,12.408,percent of total billed charges,48.48% of total billed charges,22.4,70,,17.92,percent of total billed charges,70% of total billed charges,22.4,70,,17.92,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,15.51,48.48,,12.408,percent of total billed charges,48.48% of total billed charges,28.8,90,,23.04,percent of total billed charges,90% of total billed charges,15.51,90,
NOC^ ELIQUIS TAB [5 MG],,,259,RC,,,outpatient,,,43,25.80,,25.8,60,,20.64,percent of total billed charges,60% of total billed charges,20.64,48,,16.512,percent of total billed charges,48% of total billed charges,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,30.1,70,,24.08,percent of total billed charges,70% of total billed charges,20.85,48.48,,16.68,percent of total billed charges,48.48% of total billed charges,20.85,48.48,,16.68,percent of total billed charges,48.48% of total billed charges,20.85,48.48,,16.68,percent of total billed charges,48.48% of total billed charges,30.1,70,,24.08,percent of total billed charges,70% of total billed charges,30.1,70,,24.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,20.85,48.48,,16.68,percent of total billed charges,48.48% of total billed charges,38.7,90,,30.96,percent of total billed charges,90% of total billed charges,20.85,90,
LEQVIO INJ [284 MG/1.5mL],,,636,RC,J1306,HCPCS,outpatient,284,UN,7997.44,4798.46,,4798.46,60,,3838.768,percent of total billed charges,60% of total billed charges,3838.77,48,,3071.016,percent of total billed charges,48% of total billed charges,3998.72,50,,3198.976,percent of total billed charges,50% of total billed charges,3998.72,50,,3198.976,percent of total billed charges,50% of total billed charges,3998.72,50,,3198.976,percent of total billed charges,50% of total billed charges,3998.72,50,,3198.976,percent of total billed charges,50% of total billed charges,5598.21,70,,4478.568,percent of total billed charges,70% of total billed charges,3877.16,48.48,,3101.728,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,3877.16,48.48,,3101.728,percent of total billed charges,48.48% of total billed charges,5598.21,70,,4478.568,percent of total billed charges,70% of total billed charges,5598.21,70,,4478.568,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,3877.16,48.48,,3101.728,percent of total billed charges,48.48% of total billed charges,7197.7,90,,5758.16,percent of total billed charges,90% of total billed charges,48.48,7197.7,
OXYCONTIN CR TAB [20 MG],,,259,RC,,,outpatient,,,43,25.80,,25.8,60,,20.64,percent of total billed charges,60% of total billed charges,20.64,48,,16.512,percent of total billed charges,48% of total billed charges,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,30.1,70,,24.08,percent of total billed charges,70% of total billed charges,20.85,48.48,,16.68,percent of total billed charges,48.48% of total billed charges,20.85,48.48,,16.68,percent of total billed charges,48.48% of total billed charges,20.85,48.48,,16.68,percent of total billed charges,48.48% of total billed charges,30.1,70,,24.08,percent of total billed charges,70% of total billed charges,30.1,70,,24.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,20.85,48.48,,16.68,percent of total billed charges,48.48% of total billed charges,38.7,90,,30.96,percent of total billed charges,90% of total billed charges,20.85,90,
LIDOCAINE 1G/D5 250 ML,,,636,RC,,,outpatient,,,28,16.80,,16.8,60,,13.44,percent of total billed charges,60% of total billed charges,13.44,48,,10.752,percent of total billed charges,48% of total billed charges,14,50,,11.2,percent of total billed charges,50% of total billed charges,14,50,,11.2,percent of total billed charges,50% of total billed charges,14,50,,11.2,percent of total billed charges,50% of total billed charges,14,50,,11.2,percent of total billed charges,50% of total billed charges,19.6,70,,15.68,percent of total billed charges,70% of total billed charges,13.57,48.48,,10.856,percent of total billed charges,48.48% of total billed charges,13.57,48.48,,10.856,percent of total billed charges,48.48% of total billed charges,13.57,48.48,,10.856,percent of total billed charges,48.48% of total billed charges,19.6,70,,15.68,percent of total billed charges,70% of total billed charges,19.6,70,,15.68,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,13.57,48.48,,10.856,percent of total billed charges,48.48% of total billed charges,25.2,90,,20.16,percent of total billed charges,90% of total billed charges,13.57,90,
PENTACEL VACCINE 0.5 ML,43601414,CDM,636,RC,90698,HCPCS,outpatient,,,266,159.60,,159.6,60,,127.68,percent of total billed charges,60% of total billed charges,127.68,48,,102.144,percent of total billed charges,48% of total billed charges,113.1,100,,,fee schedule,100% of bcbs custom fee schedule,113.1,100,,,fee schedule,100% of bcbs custom fee schedule,125.54,111,,,fee schedule,111% of bcbs custom fee schedule,133,50,,106.4,percent of total billed charges,50% of total billed charges,186.2,70,,148.96,percent of total billed charges,70% of total billed charges,128.96,48.48,,103.168,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,128.96,48.48,,103.168,percent of total billed charges,48.48% of total billed charges,186.2,70,,148.96,percent of total billed charges,70% of total billed charges,186.2,70,,148.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,128.96,48.48,,103.168,percent of total billed charges,48.48% of total billed charges,239.4,90,,191.52,percent of total billed charges,90% of total billed charges,48.48,239.4,
YUPELRI INH 175 MCG/3 ML,,,250,RC,,,outpatient,,,186,111.60,,111.6,60,,89.28,percent of total billed charges,60% of total billed charges,89.28,48,,71.424,percent of total billed charges,48% of total billed charges,93,50,,74.4,percent of total billed charges,50% of total billed charges,93,50,,74.4,percent of total billed charges,50% of total billed charges,93,50,,74.4,percent of total billed charges,50% of total billed charges,93,50,,74.4,percent of total billed charges,50% of total billed charges,130.2,70,,104.16,percent of total billed charges,70% of total billed charges,90.17,48.48,,72.136,percent of total billed charges,48.48% of total billed charges,90.17,48.48,,72.136,percent of total billed charges,48.48% of total billed charges,90.17,48.48,,72.136,percent of total billed charges,48.48% of total billed charges,130.2,70,,104.16,percent of total billed charges,70% of total billed charges,130.2,70,,104.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,90.17,48.48,,72.136,percent of total billed charges,48.48% of total billed charges,167.4,90,,133.92,percent of total billed charges,90% of total billed charges,48.48,167.4,
VANCOMYCIN 500MG ENEMA,,,250,RC,,,outpatient,,,52,31.20,,31.2,60,,24.96,percent of total billed charges,60% of total billed charges,24.96,48,,19.968,percent of total billed charges,48% of total billed charges,26,50,,20.8,percent of total billed charges,50% of total billed charges,26,50,,20.8,percent of total billed charges,50% of total billed charges,26,50,,20.8,percent of total billed charges,50% of total billed charges,26,50,,20.8,percent of total billed charges,50% of total billed charges,36.4,70,,29.12,percent of total billed charges,70% of total billed charges,25.21,48.48,,20.168,percent of total billed charges,48.48% of total billed charges,25.21,48.48,,20.168,percent of total billed charges,48.48% of total billed charges,25.21,48.48,,20.168,percent of total billed charges,48.48% of total billed charges,36.4,70,,29.12,percent of total billed charges,70% of total billed charges,36.4,70,,29.12,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,25.21,48.48,,20.168,percent of total billed charges,48.48% of total billed charges,46.8,90,,37.44,percent of total billed charges,90% of total billed charges,25.21,90,
NUZYRA INJ 100 MG/NS100,,,636,RC,J0121,HCPCS,outpatient,100,UN,2161,1296.60,,1296.6,60,,1037.28,percent of total billed charges,60% of total billed charges,1037.28,48,,829.824,percent of total billed charges,48% of total billed charges,3.47,100,,,fee schedule,100% of bcbs custom fee schedule,3.47,100,,,fee schedule,100% of bcbs custom fee schedule,3.85,111,,,fee schedule,111% of bcbs custom fee schedule,1080.5,50,,864.4,percent of total billed charges,50% of total billed charges,1512.7,70,,1210.16,percent of total billed charges,70% of total billed charges,1047.65,48.48,,838.12,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,1047.65,48.48,,838.12,percent of total billed charges,48.48% of total billed charges,1512.7,70,,1210.16,percent of total billed charges,70% of total billed charges,1512.7,70,,1210.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,1047.65,48.48,,838.12,percent of total billed charges,48.48% of total billed charges,1944.9,90,,1555.92,percent of total billed charges,90% of total billed charges,48.48,1944.9,
NUZYRA INJ 200 MG/NS100,,,636,RC,J0121,HCPCS,outpatient,200,UN,4322,2593.20,,2593.2,60,,2074.56,percent of total billed charges,60% of total billed charges,2074.56,48,,1659.648,percent of total billed charges,48% of total billed charges,3.47,100,,,fee schedule,100% of bcbs custom fee schedule,3.47,100,,,fee schedule,100% of bcbs custom fee schedule,3.85,111,,,fee schedule,111% of bcbs custom fee schedule,2161,50,,1728.8,percent of total billed charges,50% of total billed charges,3025.4,70,,2420.32,percent of total billed charges,70% of total billed charges,2095.31,48.48,,1676.248,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,2095.31,48.48,,1676.248,percent of total billed charges,48.48% of total billed charges,3025.4,70,,2420.32,percent of total billed charges,70% of total billed charges,3025.4,70,,2420.32,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,2095.31,48.48,,1676.248,percent of total billed charges,48.48% of total billed charges,3889.8,90,,3111.84,percent of total billed charges,90% of total billed charges,48.48,3889.8,
TEGRETOL (CARBAMAZEPINE) 200mg ER,,,259,RC,J8499,HCPCS,outpatient,1,UN,11,6.60,,6.6,60,,5.28,percent of total billed charges,60% of total billed charges,5.28,48,,4.224,percent of total billed charges,48% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,7.7,70,,6.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,5.33,48.48,,4.264,percent of total billed charges,48.48% of total billed charges,9.9,90,,7.92,percent of total billed charges,90% of total billed charges,5.33,90,
JARDIANCE 10 MG,,,259,RC,J8499,HCPCS,outpatient,1,UN,92,55.20,,55.2,60,,44.16,percent of total billed charges,60% of total billed charges,44.16,48,,35.328,percent of total billed charges,48% of total billed charges,46,50,,36.8,percent of total billed charges,50% of total billed charges,46,50,,36.8,percent of total billed charges,50% of total billed charges,46,50,,36.8,percent of total billed charges,50% of total billed charges,46,50,,36.8,percent of total billed charges,50% of total billed charges,64.4,70,,51.52,percent of total billed charges,70% of total billed charges,44.6,48.48,,35.68,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,44.6,48.48,,35.68,percent of total billed charges,48.48% of total billed charges,64.4,70,,51.52,percent of total billed charges,70% of total billed charges,64.4,70,,51.52,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,44.6,48.48,,35.68,percent of total billed charges,48.48% of total billed charges,82.8,90,,66.24,percent of total billed charges,90% of total billed charges,44.6,90,
LOPERAMIDE SOL 1MG/15ML,,,259,RC,,,outpatient,,,10,6.00,,6,60,,4.8,percent of total billed charges,60% of total billed charges,4.8,48,,3.84,percent of total billed charges,48% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,7,70,,5.6,percent of total billed charges,70% of total billed charges,4.85,48.48,,3.88,percent of total billed charges,48.48% of total billed charges,4.85,48.48,,3.88,percent of total billed charges,48.48% of total billed charges,4.85,48.48,,3.88,percent of total billed charges,48.48% of total billed charges,7,70,,5.6,percent of total billed charges,70% of total billed charges,7,70,,5.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,4.85,48.48,,3.88,percent of total billed charges,48.48% of total billed charges,9,90,,7.2,percent of total billed charges,90% of total billed charges,4.85,90,
CEFAZOLIN *IVPB* 1 GM PREMIX,,,636,RC,J0690,HCPCS,outpatient,1,UN,63,37.80,,37.8,60,,30.24,percent of total billed charges,60% of total billed charges,30.24,48,,24.192,percent of total billed charges,48% of total billed charges,1.07,100,,,fee schedule,100% of bcbs custom fee schedule,1.07,100,,,fee schedule,100% of bcbs custom fee schedule,1.19,111,,,fee schedule,111% of bcbs custom fee schedule,31.5,50,,25.2,percent of total billed charges,50% of total billed charges,44.1,70,,35.28,percent of total billed charges,70% of total billed charges,30.54,48.48,,24.432,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,30.54,48.48,,24.432,percent of total billed charges,48.48% of total billed charges,44.1,70,,35.28,percent of total billed charges,70% of total billed charges,44.1,70,,35.28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,30.54,48.48,,24.432,percent of total billed charges,48.48% of total billed charges,56.7,90,,45.36,percent of total billed charges,90% of total billed charges,30.54,90,
DIPHENHYDRAMINE * IVPB* 25 MG,,,636,RC,,,outpatient,,,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
CALCIUM GLUCONATE *IVPB*,,,636,RC,,,outpatient,,,49,29.40,,29.4,60,,23.52,percent of total billed charges,60% of total billed charges,23.52,48,,18.816,percent of total billed charges,48% of total billed charges,24.5,50,,19.6,percent of total billed charges,50% of total billed charges,24.5,50,,19.6,percent of total billed charges,50% of total billed charges,24.5,50,,19.6,percent of total billed charges,50% of total billed charges,24.5,50,,19.6,percent of total billed charges,50% of total billed charges,34.3,70,,27.44,percent of total billed charges,70% of total billed charges,23.76,48.48,,19.008,percent of total billed charges,48.48% of total billed charges,23.76,48.48,,19.008,percent of total billed charges,48.48% of total billed charges,23.76,48.48,,19.008,percent of total billed charges,48.48% of total billed charges,34.3,70,,27.44,percent of total billed charges,70% of total billed charges,34.3,70,,27.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,23.76,48.48,,19.008,percent of total billed charges,48.48% of total billed charges,44.1,90,,35.28,percent of total billed charges,90% of total billed charges,23.76,90,
AMPICILLIN *IVPB* 1 GM,,,636,RC,,,outpatient,,,33,19.80,,19.8,60,,15.84,percent of total billed charges,60% of total billed charges,15.84,48,,12.672,percent of total billed charges,48% of total billed charges,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,23.1,70,,18.48,percent of total billed charges,70% of total billed charges,16,48.48,,12.8,percent of total billed charges,48.48% of total billed charges,16,48.48,,12.8,percent of total billed charges,48.48% of total billed charges,16,48.48,,12.8,percent of total billed charges,48.48% of total billed charges,23.1,70,,18.48,percent of total billed charges,70% of total billed charges,23.1,70,,18.48,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,16,48.48,,12.8,percent of total billed charges,48.48% of total billed charges,29.7,90,,23.76,percent of total billed charges,90% of total billed charges,16,90,
AMIPICILLIN *IVPB* 500 MG,,,636,RC,,,outpatient,,,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
EPINEPHRINE INJ 1 MG/ML,,,250,RC,,,outpatient,,,70,42.00,,42,60,,33.6,percent of total billed charges,60% of total billed charges,33.6,48,,26.88,percent of total billed charges,48% of total billed charges,35,50,,28,percent of total billed charges,50% of total billed charges,35,50,,28,percent of total billed charges,50% of total billed charges,35,50,,28,percent of total billed charges,50% of total billed charges,35,50,,28,percent of total billed charges,50% of total billed charges,49,70,,39.2,percent of total billed charges,70% of total billed charges,33.94,48.48,,27.152,percent of total billed charges,48.48% of total billed charges,33.94,48.48,,27.152,percent of total billed charges,48.48% of total billed charges,33.94,48.48,,27.152,percent of total billed charges,48.48% of total billed charges,49,70,,39.2,percent of total billed charges,70% of total billed charges,49,70,,39.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,33.94,48.48,,27.152,percent of total billed charges,48.48% of total billed charges,63,90,,50.4,percent of total billed charges,90% of total billed charges,33.94,90,
NALOXONE IV DRIP 4 MG/NS 500 ML,43601517,CDM,636,RC,J2310,HCPCS,outpatient,1,UN,76,45.60,,45.6,60,,36.48,percent of total billed charges,60% of total billed charges,36.48,48,,29.184,percent of total billed charges,48% of total billed charges,12.13,100,,,fee schedule,100% of bcbs custom fee schedule,12.13,100,,,fee schedule,100% of bcbs custom fee schedule,13.46,111,,,fee schedule,111% of bcbs custom fee schedule,38,50,,30.4,percent of total billed charges,50% of total billed charges,53.2,70,,42.56,percent of total billed charges,70% of total billed charges,36.84,48.48,,29.472,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,36.84,48.48,,29.472,percent of total billed charges,48.48% of total billed charges,53.2,70,,42.56,percent of total billed charges,70% of total billed charges,53.2,70,,42.56,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,36.84,48.48,,29.472,percent of total billed charges,48.48% of total billed charges,68.4,90,,54.72,percent of total billed charges,90% of total billed charges,36.84,90,
NALOXONE IV DRIP 2 MG/NS 500 ML,,,636,RC,,,outpatient,,,76,45.60,,45.6,60,,36.48,percent of total billed charges,60% of total billed charges,36.48,48,,29.184,percent of total billed charges,48% of total billed charges,38,50,,30.4,percent of total billed charges,50% of total billed charges,38,50,,30.4,percent of total billed charges,50% of total billed charges,38,50,,30.4,percent of total billed charges,50% of total billed charges,38,50,,30.4,percent of total billed charges,50% of total billed charges,53.2,70,,42.56,percent of total billed charges,70% of total billed charges,36.84,48.48,,29.472,percent of total billed charges,48.48% of total billed charges,36.84,48.48,,29.472,percent of total billed charges,48.48% of total billed charges,36.84,48.48,,29.472,percent of total billed charges,48.48% of total billed charges,53.2,70,,42.56,percent of total billed charges,70% of total billed charges,53.2,70,,42.56,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,36.84,48.48,,29.472,percent of total billed charges,48.48% of total billed charges,68.4,90,,54.72,percent of total billed charges,90% of total billed charges,36.84,90,
NITROPRUSSIDE IV DRIP 20MG/100 ML,,,636,RC,J3490,HCPCS,outpatient,1,UN,216,129.60,,129.6,60,,103.68,percent of total billed charges,60% of total billed charges,103.68,48,,82.944,percent of total billed charges,48% of total billed charges,108,50,,86.4,percent of total billed charges,50% of total billed charges,108,50,,86.4,percent of total billed charges,50% of total billed charges,108,50,,86.4,percent of total billed charges,50% of total billed charges,108,50,,86.4,percent of total billed charges,50% of total billed charges,151.2,70,,120.96,percent of total billed charges,70% of total billed charges,104.72,48.48,,83.776,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,104.72,48.48,,83.776,percent of total billed charges,48.48% of total billed charges,151.2,70,,120.96,percent of total billed charges,70% of total billed charges,151.2,70,,120.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,104.72,48.48,,83.776,percent of total billed charges,48.48% of total billed charges,194.4,90,,155.52,percent of total billed charges,90% of total billed charges,48.48,194.4,
IMIPENEM *IVPB* 500 MG,,,636,RC,,,outpatient,,,132,79.20,,79.2,60,,63.36,percent of total billed charges,60% of total billed charges,63.36,48,,50.688,percent of total billed charges,48% of total billed charges,66,50,,52.8,percent of total billed charges,50% of total billed charges,66,50,,52.8,percent of total billed charges,50% of total billed charges,66,50,,52.8,percent of total billed charges,50% of total billed charges,66,50,,52.8,percent of total billed charges,50% of total billed charges,92.4,70,,73.92,percent of total billed charges,70% of total billed charges,63.99,48.48,,51.192,percent of total billed charges,48.48% of total billed charges,63.99,48.48,,51.192,percent of total billed charges,48.48% of total billed charges,63.99,48.48,,51.192,percent of total billed charges,48.48% of total billed charges,92.4,70,,73.92,percent of total billed charges,70% of total billed charges,92.4,70,,73.92,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,63.99,48.48,,51.192,percent of total billed charges,48.48% of total billed charges,118.8,90,,95.04,percent of total billed charges,90% of total billed charges,48.48,118.8,
IMIPENEM *IVPB* 250 MG,,,636,RC,,,outpatient,,,66,39.60,,39.6,60,,31.68,percent of total billed charges,60% of total billed charges,31.68,48,,25.344,percent of total billed charges,48% of total billed charges,33,50,,26.4,percent of total billed charges,50% of total billed charges,33,50,,26.4,percent of total billed charges,50% of total billed charges,33,50,,26.4,percent of total billed charges,50% of total billed charges,33,50,,26.4,percent of total billed charges,50% of total billed charges,46.2,70,,36.96,percent of total billed charges,70% of total billed charges,32,48.48,,25.6,percent of total billed charges,48.48% of total billed charges,32,48.48,,25.6,percent of total billed charges,48.48% of total billed charges,32,48.48,,25.6,percent of total billed charges,48.48% of total billed charges,46.2,70,,36.96,percent of total billed charges,70% of total billed charges,46.2,70,,36.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,32,48.48,,25.6,percent of total billed charges,48.48% of total billed charges,59.4,90,,47.52,percent of total billed charges,90% of total billed charges,32,90,
LABETALOL *IVPB* 100 MG,,,636,RC,J1920,HCPCS,outpatient,1,UN,125,75.00,,75,60,,60,percent of total billed charges,60% of total billed charges,60,48,,48,percent of total billed charges,48% of total billed charges,62.5,50,,50,percent of total billed charges,50% of total billed charges,62.5,50,,50,percent of total billed charges,50% of total billed charges,62.5,50,,50,percent of total billed charges,50% of total billed charges,62.5,50,,50,percent of total billed charges,50% of total billed charges,87.5,70,,70,percent of total billed charges,70% of total billed charges,60.6,48.48,,48.48,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,60.6,48.48,,48.48,percent of total billed charges,48.48% of total billed charges,87.5,70,,70,percent of total billed charges,70% of total billed charges,87.5,70,,70,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,60.6,48.48,,48.48,percent of total billed charges,48.48% of total billed charges,112.5,90,,90,percent of total billed charges,90% of total billed charges,48.48,112.5,
METHYLPREDNISOLONE *IVPB* 125 MG,,,636,RC,,,outpatient,,,47,28.20,,28.2,60,,22.56,percent of total billed charges,60% of total billed charges,22.56,48,,18.048,percent of total billed charges,48% of total billed charges,23.5,50,,18.8,percent of total billed charges,50% of total billed charges,23.5,50,,18.8,percent of total billed charges,50% of total billed charges,23.5,50,,18.8,percent of total billed charges,50% of total billed charges,23.5,50,,18.8,percent of total billed charges,50% of total billed charges,32.9,70,,26.32,percent of total billed charges,70% of total billed charges,22.79,48.48,,18.232,percent of total billed charges,48.48% of total billed charges,22.79,48.48,,18.232,percent of total billed charges,48.48% of total billed charges,22.79,48.48,,18.232,percent of total billed charges,48.48% of total billed charges,32.9,70,,26.32,percent of total billed charges,70% of total billed charges,32.9,70,,26.32,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,22.79,48.48,,18.232,percent of total billed charges,48.48% of total billed charges,42.3,90,,33.84,percent of total billed charges,90% of total billed charges,22.79,90,
TOBRAMYCIN *IVPB* 80 MG,,,636,RC,J3260,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,3.84,100,,,fee schedule,100% of bcbs custom fee schedule,3.84,100,,,fee schedule,100% of bcbs custom fee schedule,4.26,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
CEFTRIAXONE *IVPB* 250 MG,43601503,CDM,636,RC,J0696,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,0.69,100,,,fee schedule,100% of bcbs custom fee schedule,0.69,100,,,fee schedule,100% of bcbs custom fee schedule,0.77,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
AZITHROMYCIN *IVPB* 150 MG,,,636,RC,,,outpatient,,,37,22.20,,22.2,60,,17.76,percent of total billed charges,60% of total billed charges,17.76,48,,14.208,percent of total billed charges,48% of total billed charges,18.5,50,,14.8,percent of total billed charges,50% of total billed charges,18.5,50,,14.8,percent of total billed charges,50% of total billed charges,18.5,50,,14.8,percent of total billed charges,50% of total billed charges,18.5,50,,14.8,percent of total billed charges,50% of total billed charges,25.9,70,,20.72,percent of total billed charges,70% of total billed charges,17.94,48.48,,14.352,percent of total billed charges,48.48% of total billed charges,17.94,48.48,,14.352,percent of total billed charges,48.48% of total billed charges,17.94,48.48,,14.352,percent of total billed charges,48.48% of total billed charges,25.9,70,,20.72,percent of total billed charges,70% of total billed charges,25.9,70,,20.72,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,17.94,48.48,,14.352,percent of total billed charges,48.48% of total billed charges,33.3,90,,26.64,percent of total billed charges,90% of total billed charges,17.94,90,
AZITHROMYCIN *IVPB* 250 MG,,,636,RC,,,outpatient,,,37,22.20,,22.2,60,,17.76,percent of total billed charges,60% of total billed charges,17.76,48,,14.208,percent of total billed charges,48% of total billed charges,18.5,50,,14.8,percent of total billed charges,50% of total billed charges,18.5,50,,14.8,percent of total billed charges,50% of total billed charges,18.5,50,,14.8,percent of total billed charges,50% of total billed charges,18.5,50,,14.8,percent of total billed charges,50% of total billed charges,25.9,70,,20.72,percent of total billed charges,70% of total billed charges,17.94,48.48,,14.352,percent of total billed charges,48.48% of total billed charges,17.94,48.48,,14.352,percent of total billed charges,48.48% of total billed charges,17.94,48.48,,14.352,percent of total billed charges,48.48% of total billed charges,25.9,70,,20.72,percent of total billed charges,70% of total billed charges,25.9,70,,20.72,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,17.94,48.48,,14.352,percent of total billed charges,48.48% of total billed charges,33.3,90,,26.64,percent of total billed charges,90% of total billed charges,17.94,90,
AZITHROMYCIN *IVPB* 300 MG,,,636,RC,,,outpatient,,,37,22.20,,22.2,60,,17.76,percent of total billed charges,60% of total billed charges,17.76,48,,14.208,percent of total billed charges,48% of total billed charges,18.5,50,,14.8,percent of total billed charges,50% of total billed charges,18.5,50,,14.8,percent of total billed charges,50% of total billed charges,18.5,50,,14.8,percent of total billed charges,50% of total billed charges,18.5,50,,14.8,percent of total billed charges,50% of total billed charges,25.9,70,,20.72,percent of total billed charges,70% of total billed charges,17.94,48.48,,14.352,percent of total billed charges,48.48% of total billed charges,17.94,48.48,,14.352,percent of total billed charges,48.48% of total billed charges,17.94,48.48,,14.352,percent of total billed charges,48.48% of total billed charges,25.9,70,,20.72,percent of total billed charges,70% of total billed charges,25.9,70,,20.72,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,17.94,48.48,,14.352,percent of total billed charges,48.48% of total billed charges,33.3,90,,26.64,percent of total billed charges,90% of total billed charges,17.94,90,
FUROSEMIDE *IV DRIP* 100 MG,,,636,RC,,,outpatient,,,24,14.40,,14.4,60,,11.52,percent of total billed charges,60% of total billed charges,11.52,48,,9.216,percent of total billed charges,48% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,21.6,90,,17.28,percent of total billed charges,90% of total billed charges,11.64,90,
PHENYLEPHRINE *IVDRP* 10 MG (WEIGHT BASE,,,636,RC,,,outpatient,,,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
PHENYLEPHRINE *IVDRP* 10 MG (NON WEIGHT,,,636,RC,,,outpatient,,,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
GENTAMICIN *IVPB* 160 MG,43601682,CDM,636,RC,J1580,HCPCS,outpatient,2,UN,43,25.80,,25.8,60,,20.64,percent of total billed charges,60% of total billed charges,20.64,48,,16.512,percent of total billed charges,48% of total billed charges,1.97,100,,,fee schedule,100% of bcbs custom fee schedule,1.97,100,,,fee schedule,100% of bcbs custom fee schedule,2.19,111,,,fee schedule,111% of bcbs custom fee schedule,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,30.1,70,,24.08,percent of total billed charges,70% of total billed charges,20.85,48.48,,16.68,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,20.85,48.48,,16.68,percent of total billed charges,48.48% of total billed charges,30.1,70,,24.08,percent of total billed charges,70% of total billed charges,30.1,70,,24.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,20.85,48.48,,16.68,percent of total billed charges,48.48% of total billed charges,38.7,90,,30.96,percent of total billed charges,90% of total billed charges,20.85,90,
EMP-FLUZONE HIGH DOSE INJ,43601732,CDM,636,RC,90662,HCPCS,outpatient,1,UN,90,54.00,,54,60,,43.2,percent of total billed charges,60% of total billed charges,43.2,48,,34.56,percent of total billed charges,48% of total billed charges,60.98,100,,,fee schedule,100% of bcbs custom fee schedule,60.98,100,,,fee schedule,100% of bcbs custom fee schedule,67.69,111,,,fee schedule,111% of bcbs custom fee schedule,45,50,,36,percent of total billed charges,50% of total billed charges,63,70,,50.4,percent of total billed charges,70% of total billed charges,43.63,48.48,,34.904,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,43.63,48.48,,34.904,percent of total billed charges,48.48% of total billed charges,63,70,,50.4,percent of total billed charges,70% of total billed charges,63,70,,50.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,43.63,48.48,,34.904,percent of total billed charges,48.48% of total billed charges,81,90,,64.8,percent of total billed charges,90% of total billed charges,43.63,90,
DELAFLOXACIN *IVPB* 200 MG,,,636,RC,,,outpatient,,,662,397.20,,397.2,60,,317.76,percent of total billed charges,60% of total billed charges,317.76,48,,254.208,percent of total billed charges,48% of total billed charges,331,50,,264.8,percent of total billed charges,50% of total billed charges,331,50,,264.8,percent of total billed charges,50% of total billed charges,331,50,,264.8,percent of total billed charges,50% of total billed charges,331,50,,264.8,percent of total billed charges,50% of total billed charges,463.4,70,,370.72,percent of total billed charges,70% of total billed charges,320.94,48.48,,256.752,percent of total billed charges,48.48% of total billed charges,320.94,48.48,,256.752,percent of total billed charges,48.48% of total billed charges,320.94,48.48,,256.752,percent of total billed charges,48.48% of total billed charges,463.4,70,,370.72,percent of total billed charges,70% of total billed charges,463.4,70,,370.72,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,320.94,48.48,,256.752,percent of total billed charges,48.48% of total billed charges,595.8,90,,476.64,percent of total billed charges,90% of total billed charges,48.48,595.8,
TRANEXAMIC ACID 1000 MG (CONT INFUSION),,,636,RC,,,outpatient,,,35,21.00,,21,60,,16.8,percent of total billed charges,60% of total billed charges,16.8,48,,13.44,percent of total billed charges,48% of total billed charges,17.5,50,,14,percent of total billed charges,50% of total billed charges,17.5,50,,14,percent of total billed charges,50% of total billed charges,17.5,50,,14,percent of total billed charges,50% of total billed charges,17.5,50,,14,percent of total billed charges,50% of total billed charges,24.5,70,,19.6,percent of total billed charges,70% of total billed charges,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,24.5,70,,19.6,percent of total billed charges,70% of total billed charges,24.5,70,,19.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,31.5,90,,25.2,percent of total billed charges,90% of total billed charges,16.97,90,
TRANEXAMIC ACID 1000 MG (INITIAL DOSE),,,636,RC,,,outpatient,,,35,21.00,,21,60,,16.8,percent of total billed charges,60% of total billed charges,16.8,48,,13.44,percent of total billed charges,48% of total billed charges,17.5,50,,14,percent of total billed charges,50% of total billed charges,17.5,50,,14,percent of total billed charges,50% of total billed charges,17.5,50,,14,percent of total billed charges,50% of total billed charges,17.5,50,,14,percent of total billed charges,50% of total billed charges,24.5,70,,19.6,percent of total billed charges,70% of total billed charges,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,24.5,70,,19.6,percent of total billed charges,70% of total billed charges,24.5,70,,19.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,16.97,48.48,,13.576,percent of total billed charges,48.48% of total billed charges,31.5,90,,25.2,percent of total billed charges,90% of total billed charges,16.97,90,
EMP-FLUZONE VACC > 36 MO,,,636,RC,90656,HCPCS,outpatient,1,UN,40,24.00,,24,60,,19.2,percent of total billed charges,60% of total billed charges,19.2,48,,15.36,percent of total billed charges,48% of total billed charges,19.77,100,,,fee schedule,100% of bcbs custom fee schedule,19.77,100,,,fee schedule,100% of bcbs custom fee schedule,21.94,111,,,fee schedule,111% of bcbs custom fee schedule,20,50,,16,percent of total billed charges,50% of total billed charges,28,70,,22.4,percent of total billed charges,70% of total billed charges,19.39,48.48,,15.512,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,19.39,48.48,,15.512,percent of total billed charges,48.48% of total billed charges,28,70,,22.4,percent of total billed charges,70% of total billed charges,28,70,,22.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,19.39,48.48,,15.512,percent of total billed charges,48.48% of total billed charges,36,90,,28.8,percent of total billed charges,90% of total billed charges,19.39,90,
AMIKACIN *IVPB* 500 MG,,,636,RC,J0278,HCPCS,outpatient,5,UN,59,35.40,,35.4,60,,28.32,percent of total billed charges,60% of total billed charges,28.32,48,,22.656,percent of total billed charges,48% of total billed charges,1.43,100,,,fee schedule,100% of bcbs custom fee schedule,1.43,100,,,fee schedule,100% of bcbs custom fee schedule,1.59,111,,,fee schedule,111% of bcbs custom fee schedule,29.5,50,,23.6,percent of total billed charges,50% of total billed charges,41.3,70,,33.04,percent of total billed charges,70% of total billed charges,28.6,48.48,,22.88,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,28.6,48.48,,22.88,percent of total billed charges,48.48% of total billed charges,41.3,70,,33.04,percent of total billed charges,70% of total billed charges,41.3,70,,33.04,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,28.6,48.48,,22.88,percent of total billed charges,48.48% of total billed charges,53.1,90,,42.48,percent of total billed charges,90% of total billed charges,28.6,90,
PHENYTION *IVPB* 100 MG,,,636,RC,,,outpatient,,,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
AMPICILLIN *IVPB* 500 MG/D5W,,,636,RC,,,outpatient,,,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
PROMETHAZINE *IVPB* 25 MG,,,636,RC,,,outpatient,,,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
PROTAMINE *IVPB* 50 MG,,,636,RC,,,outpatient,,,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
VANCOMYCIN IVPB 500 MG PRMX,,,636,RC,J3370,HCPCS,outpatient,,,52,31.20,,31.2,60,,24.96,percent of total billed charges,60% of total billed charges,24.96,48,,19.968,percent of total billed charges,48% of total billed charges,3.05,100,,,fee schedule,100% of bcbs custom fee schedule,3.05,100,,,fee schedule,100% of bcbs custom fee schedule,3.39,111,,,fee schedule,111% of bcbs custom fee schedule,26,50,,20.8,percent of total billed charges,50% of total billed charges,36.4,70,,29.12,percent of total billed charges,70% of total billed charges,25.21,48.48,,20.168,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,25.21,48.48,,20.168,percent of total billed charges,48.48% of total billed charges,36.4,70,,29.12,percent of total billed charges,70% of total billed charges,36.4,70,,29.12,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,25.21,48.48,,20.168,percent of total billed charges,48.48% of total billed charges,46.8,90,,37.44,percent of total billed charges,90% of total billed charges,25.21,90,
CEFTRIAXONE *IVPB* 500 MG,,,636,RC,,,outpatient,1,UN,30,18.00,,18,60,,14.4,percent of total billed charges,60% of total billed charges,14.4,48,,11.52,percent of total billed charges,48% of total billed charges,15,50,,12,percent of total billed charges,50% of total billed charges,15,50,,12,percent of total billed charges,50% of total billed charges,15,50,,12,percent of total billed charges,50% of total billed charges,15,50,,12,percent of total billed charges,50% of total billed charges,21,70,,16.8,percent of total billed charges,70% of total billed charges,14.54,48.48,,11.632,percent of total billed charges,48.48% of total billed charges,14.54,48.48,,11.632,percent of total billed charges,48.48% of total billed charges,14.54,48.48,,11.632,percent of total billed charges,48.48% of total billed charges,21,70,,16.8,percent of total billed charges,70% of total billed charges,21,70,,16.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,14.54,48.48,,11.632,percent of total billed charges,48.48% of total billed charges,27,90,,21.6,percent of total billed charges,90% of total billed charges,14.54,90,
NOREPINEPHRINE *IVDRIP* 8 MG,,,636,RC,J3490,HCPCS,outpatient,1,UN,236,141.60,,141.6,60,,113.28,percent of total billed charges,60% of total billed charges,113.28,48,,90.624,percent of total billed charges,48% of total billed charges,118,50,,94.4,percent of total billed charges,50% of total billed charges,118,50,,94.4,percent of total billed charges,50% of total billed charges,118,50,,94.4,percent of total billed charges,50% of total billed charges,118,50,,94.4,percent of total billed charges,50% of total billed charges,165.2,70,,132.16,percent of total billed charges,70% of total billed charges,114.41,48.48,,91.528,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,114.41,48.48,,91.528,percent of total billed charges,48.48% of total billed charges,165.2,70,,132.16,percent of total billed charges,70% of total billed charges,165.2,70,,132.16,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,114.41,48.48,,91.528,percent of total billed charges,48.48% of total billed charges,212.4,90,,169.92,percent of total billed charges,90% of total billed charges,48.48,212.4,
EMP- FLUZONE VACC (FLUBLOK),,,636,RC,90673,HCPCS,outpatient,1,UN,90,54.00,,54,60,,43.2,percent of total billed charges,60% of total billed charges,43.2,48,,34.56,percent of total billed charges,48% of total billed charges,40.61,100,,,fee schedule,100% of bcbs custom fee schedule,40.61,100,,,fee schedule,100% of bcbs custom fee schedule,45.08,111,,,fee schedule,111% of bcbs custom fee schedule,45,50,,36,percent of total billed charges,50% of total billed charges,63,70,,50.4,percent of total billed charges,70% of total billed charges,43.63,48.48,,34.904,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,43.63,48.48,,34.904,percent of total billed charges,48.48% of total billed charges,63,70,,50.4,percent of total billed charges,70% of total billed charges,63,70,,50.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,43.63,48.48,,34.904,percent of total billed charges,48.48% of total billed charges,81,90,,64.8,percent of total billed charges,90% of total billed charges,43.63,90,
METHENAMINE TAB 1G,,,259,RC,J8499,HCPCS,outpatient,1,UN,14,8.40,,8.4,60,,6.72,percent of total billed charges,60% of total billed charges,6.72,48,,5.376,percent of total billed charges,48% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,9.8,70,,7.84,percent of total billed charges,70% of total billed charges,6.79,48.48,,5.432,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,6.79,48.48,,5.432,percent of total billed charges,48.48% of total billed charges,9.8,70,,7.84,percent of total billed charges,70% of total billed charges,9.8,70,,7.84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,6.79,48.48,,5.432,percent of total billed charges,48.48% of total billed charges,12.6,90,,10.08,percent of total billed charges,90% of total billed charges,6.79,90,
TEMAZEPAM CAP 7.5 MG,,,259,RC,J8499,HCPCS,outpatient,1,UN,34,20.40,,20.4,60,,16.32,percent of total billed charges,60% of total billed charges,16.32,48,,13.056,percent of total billed charges,48% of total billed charges,17,50,,13.6,percent of total billed charges,50% of total billed charges,17,50,,13.6,percent of total billed charges,50% of total billed charges,17,50,,13.6,percent of total billed charges,50% of total billed charges,17,50,,13.6,percent of total billed charges,50% of total billed charges,23.8,70,,19.04,percent of total billed charges,70% of total billed charges,16.48,48.48,,13.184,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,16.48,48.48,,13.184,percent of total billed charges,48.48% of total billed charges,23.8,70,,19.04,percent of total billed charges,70% of total billed charges,23.8,70,,19.04,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,16.48,48.48,,13.184,percent of total billed charges,48.48% of total billed charges,30.6,90,,24.48,percent of total billed charges,90% of total billed charges,16.48,90,
VYVGART INJ 400 MG/20 ML,,,636,RC,J9332,HCPCS,outpatient,200,UN,72.83,43.70,,43.7,60,,34.96,percent of total billed charges,60% of total billed charges,34.96,48,,27.968,percent of total billed charges,48% of total billed charges,36.42,50,,29.136,percent of total billed charges,50% of total billed charges,36.42,50,,29.136,percent of total billed charges,50% of total billed charges,36.42,50,,29.136,percent of total billed charges,50% of total billed charges,36.42,50,,29.136,percent of total billed charges,50% of total billed charges,50.98,70,,40.784,percent of total billed charges,70% of total billed charges,35.31,48.48,,28.248,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,35.31,48.48,,28.248,percent of total billed charges,48.48% of total billed charges,50.98,70,,40.784,percent of total billed charges,70% of total billed charges,50.98,70,,40.784,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,35.31,48.48,,28.248,percent of total billed charges,48.48% of total billed charges,65.55,90,,52.44,percent of total billed charges,90% of total billed charges,35.31,90,
MAGIC MOUTHWASH (BML) 4 OZ,,,259,RC,J3490,HCPCS,outpatient,1,UN,360,216.00,,216,60,,172.8,percent of total billed charges,60% of total billed charges,172.8,48,,138.24,percent of total billed charges,48% of total billed charges,180,50,,144,percent of total billed charges,50% of total billed charges,180,50,,144,percent of total billed charges,50% of total billed charges,180,50,,144,percent of total billed charges,50% of total billed charges,180,50,,144,percent of total billed charges,50% of total billed charges,252,70,,201.6,percent of total billed charges,70% of total billed charges,174.53,48.48,,139.624,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,174.53,48.48,,139.624,percent of total billed charges,48.48% of total billed charges,252,70,,201.6,percent of total billed charges,70% of total billed charges,252,70,,201.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,174.53,48.48,,139.624,percent of total billed charges,48.48% of total billed charges,324,90,,259.2,percent of total billed charges,90% of total billed charges,48.48,324,
ULTOMIRIS INJ 2400 MG,,,636,RC,J1303,HCPCS,outpatient,240,UN,122957,73774.20,,73774.2,60,,59019.36,percent of total billed charges,60% of total billed charges,59019.36,48,,47215.488,percent of total billed charges,48% of total billed charges,216.46,100,,,fee schedule,100% of bcbs custom fee schedule,216.46,100,,,fee schedule,100% of bcbs custom fee schedule,240.27,111,,,fee schedule,111% of bcbs custom fee schedule,61478.5,50,,49182.8,percent of total billed charges,50% of total billed charges,86069.9,70,,68855.92,percent of total billed charges,70% of total billed charges,59609.55,48.48,,47687.64,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,59609.55,48.48,,47687.64,percent of total billed charges,48.48% of total billed charges,86069.9,70,,68855.92,percent of total billed charges,70% of total billed charges,86069.9,70,,68855.92,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,59609.55,48.48,,47687.64,percent of total billed charges,48.48% of total billed charges,110661.3,90,,88529.04,percent of total billed charges,90% of total billed charges,48.48,110661.3,
ULTOMIRIS INJ 3000 MG,,,636,RC,J1303,HCPCS,outpatient,300,UN,153696,92217.60,,92217.6,60,,73774.08,percent of total billed charges,60% of total billed charges,73774.08,48,,59019.264,percent of total billed charges,48% of total billed charges,216.46,100,,,fee schedule,100% of bcbs custom fee schedule,216.46,100,,,fee schedule,100% of bcbs custom fee schedule,240.27,111,,,fee schedule,111% of bcbs custom fee schedule,76848,50,,61478.4,percent of total billed charges,50% of total billed charges,107587.2,70,,86069.76,percent of total billed charges,70% of total billed charges,74511.82,48.48,,59609.456,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,74511.82,48.48,,59609.456,percent of total billed charges,48.48% of total billed charges,107587.2,70,,86069.76,percent of total billed charges,70% of total billed charges,107587.2,70,,86069.76,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,74511.82,48.48,,59609.456,percent of total billed charges,48.48% of total billed charges,138326.4,90,,110661.12,percent of total billed charges,90% of total billed charges,48.48,138326.4,
URSODIOL CAP 300 MG,,,259,RC,J8499,HCPCS,outpatient,1,UN,31,18.60,,18.6,60,,14.88,percent of total billed charges,60% of total billed charges,14.88,48,,11.904,percent of total billed charges,48% of total billed charges,15.5,50,,12.4,percent of total billed charges,50% of total billed charges,15.5,50,,12.4,percent of total billed charges,50% of total billed charges,15.5,50,,12.4,percent of total billed charges,50% of total billed charges,15.5,50,,12.4,percent of total billed charges,50% of total billed charges,21.7,70,,17.36,percent of total billed charges,70% of total billed charges,15.03,48.48,,12.024,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,15.03,48.48,,12.024,percent of total billed charges,48.48% of total billed charges,21.7,70,,17.36,percent of total billed charges,70% of total billed charges,21.7,70,,17.36,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,15.03,48.48,,12.024,percent of total billed charges,48.48% of total billed charges,27.9,90,,22.32,percent of total billed charges,90% of total billed charges,15.03,90,
HEP B VACC 110MCG/0.5ML,43601425,CDM,636,RC,90744,HCPCS,outpatient,1,UN,66,39.60,,39.6,60,,31.68,percent of total billed charges,60% of total billed charges,31.68,48,,25.344,percent of total billed charges,48% of total billed charges,31.03,100,,,fee schedule,100% of bcbs custom fee schedule,31.03,100,,,fee schedule,100% of bcbs custom fee schedule,34.44,111,,,fee schedule,111% of bcbs custom fee schedule,33,50,,26.4,percent of total billed charges,50% of total billed charges,46.2,70,,36.96,percent of total billed charges,70% of total billed charges,32,48.48,,25.6,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,32,48.48,,25.6,percent of total billed charges,48.48% of total billed charges,46.2,70,,36.96,percent of total billed charges,70% of total billed charges,46.2,70,,36.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,32,48.48,,25.6,percent of total billed charges,48.48% of total billed charges,59.4,90,,47.52,percent of total billed charges,90% of total billed charges,32,90,
CIPRODEX OTIC 7.5ML,,,259,RC,J3490,HCPCS,outpatient,1,UN,1077,646.20,,646.2,60,,516.96,percent of total billed charges,60% of total billed charges,516.96,48,,413.568,percent of total billed charges,48% of total billed charges,538.5,50,,430.8,percent of total billed charges,50% of total billed charges,538.5,50,,430.8,percent of total billed charges,50% of total billed charges,538.5,50,,430.8,percent of total billed charges,50% of total billed charges,538.5,50,,430.8,percent of total billed charges,50% of total billed charges,753.9,70,,603.12,percent of total billed charges,70% of total billed charges,522.13,48.48,,417.704,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,522.13,48.48,,417.704,percent of total billed charges,48.48% of total billed charges,753.9,70,,603.12,percent of total billed charges,70% of total billed charges,753.9,70,,603.12,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,522.13,48.48,,417.704,percent of total billed charges,48.48% of total billed charges,969.3,90,,775.44,percent of total billed charges,90% of total billed charges,48.48,969.3,
EVENITY 210 MG,,,636,RC,J3111,HCPCS,outpatient,210,UN,25.53,15.32,,15.32,60,,12.256,percent of total billed charges,60% of total billed charges,12.25,48,,9.8,percent of total billed charges,48% of total billed charges,9.11,100,,,fee schedule,100% of bcbs custom fee schedule,9.11,100,,,fee schedule,100% of bcbs custom fee schedule,10.11,111,,,fee schedule,111% of bcbs custom fee schedule,12.77,50,,10.216,percent of total billed charges,50% of total billed charges,17.87,70,,14.296,percent of total billed charges,70% of total billed charges,12.38,48.48,,9.904,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,12.38,48.48,,9.904,percent of total billed charges,48.48% of total billed charges,17.87,70,,14.296,percent of total billed charges,70% of total billed charges,17.87,70,,14.296,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,12.38,48.48,,9.904,percent of total billed charges,48.48% of total billed charges,22.98,90,,18.384,percent of total billed charges,90% of total billed charges,12.38,90,
NAMENDA XR 21 MG,,,259,RC,J8499,HCPCS,outpatient,1,UN,62,37.20,,37.2,60,,29.76,percent of total billed charges,60% of total billed charges,29.76,48,,23.808,percent of total billed charges,48% of total billed charges,31,50,,24.8,percent of total billed charges,50% of total billed charges,31,50,,24.8,percent of total billed charges,50% of total billed charges,31,50,,24.8,percent of total billed charges,50% of total billed charges,31,50,,24.8,percent of total billed charges,50% of total billed charges,43.4,70,,34.72,percent of total billed charges,70% of total billed charges,30.06,48.48,,24.048,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,30.06,48.48,,24.048,percent of total billed charges,48.48% of total billed charges,43.4,70,,34.72,percent of total billed charges,70% of total billed charges,43.4,70,,34.72,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,30.06,48.48,,24.048,percent of total billed charges,48.48% of total billed charges,55.8,90,,44.64,percent of total billed charges,90% of total billed charges,30.06,90,
LIDOCAINE 4% PATCH,,,259,RC,J3490,HCPCS,outpatient,1,UN,13,7.80,,7.8,60,,6.24,percent of total billed charges,60% of total billed charges,6.24,48,,4.992,percent of total billed charges,48% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,9.1,70,,7.28,percent of total billed charges,70% of total billed charges,6.3,48.48,,5.04,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,6.3,48.48,,5.04,percent of total billed charges,48.48% of total billed charges,9.1,70,,7.28,percent of total billed charges,70% of total billed charges,9.1,70,,7.28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,6.3,48.48,,5.04,percent of total billed charges,48.48% of total billed charges,11.7,90,,9.36,percent of total billed charges,90% of total billed charges,6.3,90,
CINACALCET TAB 30 MG,,,259,RC,J8499,HCPCS,outpatient,1,UN,123,73.80,,73.8,60,,59.04,percent of total billed charges,60% of total billed charges,59.04,48,,47.232,percent of total billed charges,48% of total billed charges,61.5,50,,49.2,percent of total billed charges,50% of total billed charges,61.5,50,,49.2,percent of total billed charges,50% of total billed charges,61.5,50,,49.2,percent of total billed charges,50% of total billed charges,61.5,50,,49.2,percent of total billed charges,50% of total billed charges,86.1,70,,68.88,percent of total billed charges,70% of total billed charges,59.63,48.48,,47.704,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,59.63,48.48,,47.704,percent of total billed charges,48.48% of total billed charges,86.1,70,,68.88,percent of total billed charges,70% of total billed charges,86.1,70,,68.88,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,59.63,48.48,,47.704,percent of total billed charges,48.48% of total billed charges,110.7,90,,88.56,percent of total billed charges,90% of total billed charges,48.48,110.7,
CLINDAMYCIN SUSP 75 MG/5 ML,,,259,RC,J3490,HCPCS,outpatient,1,UN,248.1,148.86,,148.86,60,,119.088,percent of total billed charges,60% of total billed charges,119.09,48,,95.272,percent of total billed charges,48% of total billed charges,124.05,50,,99.24,percent of total billed charges,50% of total billed charges,124.05,50,,99.24,percent of total billed charges,50% of total billed charges,124.05,50,,99.24,percent of total billed charges,50% of total billed charges,124.05,50,,99.24,percent of total billed charges,50% of total billed charges,173.67,70,,138.936,percent of total billed charges,70% of total billed charges,120.28,48.48,,96.224,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,120.28,48.48,,96.224,percent of total billed charges,48.48% of total billed charges,173.67,70,,138.936,percent of total billed charges,70% of total billed charges,173.67,70,,138.936,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,120.28,48.48,,96.224,percent of total billed charges,48.48% of total billed charges,223.29,90,,178.632,percent of total billed charges,90% of total billed charges,48.48,223.29,
EPI-PEN JR,43601500,CDM,636,RC,J0171,HCPCS,outpatient,1,UN,1460,876.00,,876,60,,700.8,percent of total billed charges,60% of total billed charges,700.8,48,,560.64,percent of total billed charges,48% of total billed charges,0.97,100,,,fee schedule,100% of bcbs custom fee schedule,0.97,100,,,fee schedule,100% of bcbs custom fee schedule,1.08,111,,,fee schedule,111% of bcbs custom fee schedule,730,50,,584,percent of total billed charges,50% of total billed charges,1022,70,,817.6,percent of total billed charges,70% of total billed charges,707.81,48.48,,566.248,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,707.81,48.48,,566.248,percent of total billed charges,48.48% of total billed charges,1022,70,,817.6,percent of total billed charges,70% of total billed charges,1022,70,,817.6,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,707.81,48.48,,566.248,percent of total billed charges,48.48% of total billed charges,1314,90,,1051.2,percent of total billed charges,90% of total billed charges,48.48,1314,
MAGNESIUM GLYCINATE 200 MG,,,259,RC,J8499,HCPCS,outpatient,1,UN,28,16.80,,16.8,60,,13.44,percent of total billed charges,60% of total billed charges,13.44,48,,10.752,percent of total billed charges,48% of total billed charges,14,50,,11.2,percent of total billed charges,50% of total billed charges,14,50,,11.2,percent of total billed charges,50% of total billed charges,14,50,,11.2,percent of total billed charges,50% of total billed charges,14,50,,11.2,percent of total billed charges,50% of total billed charges,19.6,70,,15.68,percent of total billed charges,70% of total billed charges,13.57,48.48,,10.856,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,13.57,48.48,,10.856,percent of total billed charges,48.48% of total billed charges,19.6,70,,15.68,percent of total billed charges,70% of total billed charges,19.6,70,,15.68,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,13.57,48.48,,10.856,percent of total billed charges,48.48% of total billed charges,25.2,90,,20.16,percent of total billed charges,90% of total billed charges,13.57,90,
ACETADOTE 6G/30 ML VIAL,,,636,RC,J0132,HCPCS,outpatient,1,UN,1098,658.80,,658.8,60,,527.04,percent of total billed charges,60% of total billed charges,527.04,48,,421.632,percent of total billed charges,48% of total billed charges,1.17,100,,,fee schedule,100% of bcbs custom fee schedule,1.17,100,,,fee schedule,100% of bcbs custom fee schedule,1.3,111,,,fee schedule,111% of bcbs custom fee schedule,549,50,,439.2,percent of total billed charges,50% of total billed charges,768.6,70,,614.88,percent of total billed charges,70% of total billed charges,532.31,48.48,,425.848,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,532.31,48.48,,425.848,percent of total billed charges,48.48% of total billed charges,768.6,70,,614.88,percent of total billed charges,70% of total billed charges,768.6,70,,614.88,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,532.31,48.48,,425.848,percent of total billed charges,48.48% of total billed charges,988.2,90,,790.56,percent of total billed charges,90% of total billed charges,48.48,988.2,
NEUPOGEN 480 MCG INJ,,,636,RC,J1442,HCPCS,outpatient,1,UN,2544,1526.40,,1526.4,60,,1221.12,percent of total billed charges,60% of total billed charges,1221.12,48,,976.896,percent of total billed charges,48% of total billed charges,0.52,100,,,fee schedule,100% of bcbs custom fee schedule,0.52,100,,,fee schedule,100% of bcbs custom fee schedule,0.58,111,,,fee schedule,111% of bcbs custom fee schedule,1272,50,,1017.6,percent of total billed charges,50% of total billed charges,1780.8,70,,1424.64,percent of total billed charges,70% of total billed charges,1233.33,48.48,,986.664,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,1233.33,48.48,,986.664,percent of total billed charges,48.48% of total billed charges,1780.8,70,,1424.64,percent of total billed charges,70% of total billed charges,1780.8,70,,1424.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,1233.33,48.48,,986.664,percent of total billed charges,48.48% of total billed charges,2289.6,90,,1831.68,percent of total billed charges,90% of total billed charges,48.48,2289.6,
NICARDIPINE 25MG/10ML,,,636,RC,J3490,HCPCS,outpatient,1,UN,42,25.20,,25.2,60,,20.16,percent of total billed charges,60% of total billed charges,20.16,48,,16.128,percent of total billed charges,48% of total billed charges,21,50,,16.8,percent of total billed charges,50% of total billed charges,21,50,,16.8,percent of total billed charges,50% of total billed charges,21,50,,16.8,percent of total billed charges,50% of total billed charges,21,50,,16.8,percent of total billed charges,50% of total billed charges,29.4,70,,23.52,percent of total billed charges,70% of total billed charges,20.36,48.48,,16.288,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,20.36,48.48,,16.288,percent of total billed charges,48.48% of total billed charges,29.4,70,,23.52,percent of total billed charges,70% of total billed charges,29.4,70,,23.52,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,20.36,48.48,,16.288,percent of total billed charges,48.48% of total billed charges,37.8,90,,30.24,percent of total billed charges,90% of total billed charges,20.36,90,
ACYCLOVIR 1GM VIAL,,,636,RC,J0133,HCPCS,outpatient,1,UN,144,86.40,,86.4,60,,69.12,percent of total billed charges,60% of total billed charges,69.12,48,,55.296,percent of total billed charges,48% of total billed charges,0.06,100,,,fee schedule,100% of bcbs custom fee schedule,0.06,100,,,fee schedule,100% of bcbs custom fee schedule,0.07,111,,,fee schedule,111% of bcbs custom fee schedule,72,50,,57.6,percent of total billed charges,50% of total billed charges,100.8,70,,80.64,percent of total billed charges,70% of total billed charges,69.81,48.48,,55.848,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,69.81,48.48,,55.848,percent of total billed charges,48.48% of total billed charges,100.8,70,,80.64,percent of total billed charges,70% of total billed charges,100.8,70,,80.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,69.81,48.48,,55.848,percent of total billed charges,48.48% of total billed charges,129.6,90,,103.68,percent of total billed charges,90% of total billed charges,48.48,129.6,
LOKELMA PKT 5G,,,259,RC,J8499,HCPCS,outpatient,1,UN,132,79.20,,79.2,60,,63.36,percent of total billed charges,60% of total billed charges,63.36,48,,50.688,percent of total billed charges,48% of total billed charges,66,50,,52.8,percent of total billed charges,50% of total billed charges,66,50,,52.8,percent of total billed charges,50% of total billed charges,66,50,,52.8,percent of total billed charges,50% of total billed charges,66,50,,52.8,percent of total billed charges,50% of total billed charges,92.4,70,,73.92,percent of total billed charges,70% of total billed charges,63.99,48.48,,51.192,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,63.99,48.48,,51.192,percent of total billed charges,48.48% of total billed charges,92.4,70,,73.92,percent of total billed charges,70% of total billed charges,92.4,70,,73.92,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,63.99,48.48,,51.192,percent of total billed charges,48.48% of total billed charges,118.8,90,,95.04,percent of total billed charges,90% of total billed charges,48.48,118.8,
VOLTAREN GEL 50G,,,259,RC,J3490,HCPCS,outpatient,1,UN,45,27.00,,27,60,,21.6,percent of total billed charges,60% of total billed charges,21.6,48,,17.28,percent of total billed charges,48% of total billed charges,22.5,50,,18,percent of total billed charges,50% of total billed charges,22.5,50,,18,percent of total billed charges,50% of total billed charges,22.5,50,,18,percent of total billed charges,50% of total billed charges,22.5,50,,18,percent of total billed charges,50% of total billed charges,31.5,70,,25.2,percent of total billed charges,70% of total billed charges,21.82,48.48,,17.456,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,21.82,48.48,,17.456,percent of total billed charges,48.48% of total billed charges,31.5,70,,25.2,percent of total billed charges,70% of total billed charges,31.5,70,,25.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,21.82,48.48,,17.456,percent of total billed charges,48.48% of total billed charges,40.5,90,,32.4,percent of total billed charges,90% of total billed charges,21.82,90,
LIDOCAINE 1% SYR [50MG/5ML],,,636,RC,J2001,HCPCS,outpatient,1,UN,55,33.00,,33,60,,26.4,percent of total billed charges,60% of total billed charges,26.4,48,,21.12,percent of total billed charges,48% of total billed charges,0.02,100,,,fee schedule,100% of bcbs custom fee schedule,0.02,100,,,fee schedule,100% of bcbs custom fee schedule,0.02,111,,,fee schedule,111% of bcbs custom fee schedule,27.5,50,,22,percent of total billed charges,50% of total billed charges,38.5,70,,30.8,percent of total billed charges,70% of total billed charges,26.66,48.48,,21.328,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,26.66,48.48,,21.328,percent of total billed charges,48.48% of total billed charges,38.5,70,,30.8,percent of total billed charges,70% of total billed charges,38.5,70,,30.8,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,26.66,48.48,,21.328,percent of total billed charges,48.48% of total billed charges,49.5,90,,39.6,percent of total billed charges,90% of total billed charges,26.66,90,
BELSOMRA TAB [10 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,72,43.20,,43.2,60,,34.56,percent of total billed charges,60% of total billed charges,34.56,48,,27.648,percent of total billed charges,48% of total billed charges,36,50,,28.8,percent of total billed charges,50% of total billed charges,36,50,,28.8,percent of total billed charges,50% of total billed charges,36,50,,28.8,percent of total billed charges,50% of total billed charges,36,50,,28.8,percent of total billed charges,50% of total billed charges,50.4,70,,40.32,percent of total billed charges,70% of total billed charges,34.91,48.48,,27.928,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,34.91,48.48,,27.928,percent of total billed charges,48.48% of total billed charges,50.4,70,,40.32,percent of total billed charges,70% of total billed charges,50.4,70,,40.32,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,34.91,48.48,,27.928,percent of total billed charges,48.48% of total billed charges,64.8,90,,51.84,percent of total billed charges,90% of total billed charges,34.91,90,
GLUCAGON IM/IV INJ 1 MG,,,636,RC,J1611,HCPCS,outpatient,1,UN,1064,638.40,,638.4,60,,510.72,percent of total billed charges,60% of total billed charges,510.72,48,,408.576,percent of total billed charges,48% of total billed charges,532,50,,425.6,percent of total billed charges,50% of total billed charges,532,50,,425.6,percent of total billed charges,50% of total billed charges,532,50,,425.6,percent of total billed charges,50% of total billed charges,532,50,,425.6,percent of total billed charges,50% of total billed charges,744.8,70,,595.84,percent of total billed charges,70% of total billed charges,515.83,48.48,,412.664,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,515.83,48.48,,412.664,percent of total billed charges,48.48% of total billed charges,744.8,70,,595.84,percent of total billed charges,70% of total billed charges,744.8,70,,595.84,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,515.83,48.48,,412.664,percent of total billed charges,48.48% of total billed charges,957.6,90,,766.08,percent of total billed charges,90% of total billed charges,48.48,957.6,
DIFICID TABLET,,,259,RC,J8499,HCPCS,outpatient,1,UN,598,358.80,,358.8,60,,287.04,percent of total billed charges,60% of total billed charges,287.04,48,,229.632,percent of total billed charges,48% of total billed charges,299,50,,239.2,percent of total billed charges,50% of total billed charges,299,50,,239.2,percent of total billed charges,50% of total billed charges,299,50,,239.2,percent of total billed charges,50% of total billed charges,299,50,,239.2,percent of total billed charges,50% of total billed charges,418.6,70,,334.88,percent of total billed charges,70% of total billed charges,289.91,48.48,,231.928,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,289.91,48.48,,231.928,percent of total billed charges,48.48% of total billed charges,418.6,70,,334.88,percent of total billed charges,70% of total billed charges,418.6,70,,334.88,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,289.91,48.48,,231.928,percent of total billed charges,48.48% of total billed charges,538.2,90,,430.56,percent of total billed charges,90% of total billed charges,48.48,538.2,
NALOXONE NASAL SPRAY,,,250,RC,J3490,HCPCS,outpatient,1,UN,192,115.20,,115.2,60,,92.16,percent of total billed charges,60% of total billed charges,92.16,48,,73.728,percent of total billed charges,48% of total billed charges,96,50,,76.8,percent of total billed charges,50% of total billed charges,96,50,,76.8,percent of total billed charges,50% of total billed charges,96,50,,76.8,percent of total billed charges,50% of total billed charges,96,50,,76.8,percent of total billed charges,50% of total billed charges,134.4,70,,107.52,percent of total billed charges,70% of total billed charges,93.08,48.48,,74.464,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,93.08,48.48,,74.464,percent of total billed charges,48.48% of total billed charges,134.4,70,,107.52,percent of total billed charges,70% of total billed charges,134.4,70,,107.52,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,93.08,48.48,,74.464,percent of total billed charges,48.48% of total billed charges,172.8,90,,138.24,percent of total billed charges,90% of total billed charges,48.48,172.8,
DAPTOMYCIN *IVPB* 350 MG,,,636,RC,J0878,HCPCS,outpatient,1,UN,315,189.00,,189,60,,151.2,percent of total billed charges,60% of total billed charges,151.2,48,,120.96,percent of total billed charges,48% of total billed charges,0.18,100,,,fee schedule,100% of bcbs custom fee schedule,0.18,100,,,fee schedule,100% of bcbs custom fee schedule,0.2,111,,,fee schedule,111% of bcbs custom fee schedule,157.5,50,,126,percent of total billed charges,50% of total billed charges,220.5,70,,176.4,percent of total billed charges,70% of total billed charges,152.71,48.48,,122.168,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,152.71,48.48,,122.168,percent of total billed charges,48.48% of total billed charges,220.5,70,,176.4,percent of total billed charges,70% of total billed charges,220.5,70,,176.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,152.71,48.48,,122.168,percent of total billed charges,48.48% of total billed charges,283.5,90,,226.8,percent of total billed charges,90% of total billed charges,48.48,283.5,
ALOGLIPTIN TAB (25 MG),,,259,RC,J8499,HCPCS,outpatient,1,UN,32,19.20,,19.2,60,,15.36,percent of total billed charges,60% of total billed charges,15.36,48,,12.288,percent of total billed charges,48% of total billed charges,16,50,,12.8,percent of total billed charges,50% of total billed charges,16,50,,12.8,percent of total billed charges,50% of total billed charges,16,50,,12.8,percent of total billed charges,50% of total billed charges,16,50,,12.8,percent of total billed charges,50% of total billed charges,22.4,70,,17.92,percent of total billed charges,70% of total billed charges,15.51,48.48,,12.408,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,15.51,48.48,,12.408,percent of total billed charges,48.48% of total billed charges,22.4,70,,17.92,percent of total billed charges,70% of total billed charges,22.4,70,,17.92,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,15.51,48.48,,12.408,percent of total billed charges,48.48% of total billed charges,28.8,90,,23.04,percent of total billed charges,90% of total billed charges,15.51,90,
DILTIAZEM ER CAP (60 MG),,,259,RC,J8499,HCPCS,outpatient,1,UN,16,9.60,,9.6,60,,7.68,percent of total billed charges,60% of total billed charges,7.68,48,,6.144,percent of total billed charges,48% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,11.2,70,,8.96,percent of total billed charges,70% of total billed charges,7.76,48.48,,6.208,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,7.76,48.48,,6.208,percent of total billed charges,48.48% of total billed charges,11.2,70,,8.96,percent of total billed charges,70% of total billed charges,11.2,70,,8.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,7.76,48.48,,6.208,percent of total billed charges,48.48% of total billed charges,14.4,90,,11.52,percent of total billed charges,90% of total billed charges,7.76,90,
SLOW FE CAPLET 30CT,,,259,RC,J3490,HCPCS,outpatient,1,UN,38,22.80,,22.8,60,,18.24,percent of total billed charges,60% of total billed charges,18.24,48,,14.592,percent of total billed charges,48% of total billed charges,19,50,,15.2,percent of total billed charges,50% of total billed charges,19,50,,15.2,percent of total billed charges,50% of total billed charges,19,50,,15.2,percent of total billed charges,50% of total billed charges,19,50,,15.2,percent of total billed charges,50% of total billed charges,26.6,70,,21.28,percent of total billed charges,70% of total billed charges,18.42,48.48,,14.736,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,18.42,48.48,,14.736,percent of total billed charges,48.48% of total billed charges,26.6,70,,21.28,percent of total billed charges,70% of total billed charges,26.6,70,,21.28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,18.42,48.48,,14.736,percent of total billed charges,48.48% of total billed charges,34.2,90,,27.36,percent of total billed charges,90% of total billed charges,18.42,90,
DIVALPROEX DR  [500 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,13,7.80,,7.8,60,,6.24,percent of total billed charges,60% of total billed charges,6.24,48,,4.992,percent of total billed charges,48% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,9.1,70,,7.28,percent of total billed charges,70% of total billed charges,6.3,48.48,,5.04,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,6.3,48.48,,5.04,percent of total billed charges,48.48% of total billed charges,9.1,70,,7.28,percent of total billed charges,70% of total billed charges,9.1,70,,7.28,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,6.3,48.48,,5.04,percent of total billed charges,48.48% of total billed charges,11.7,90,,9.36,percent of total billed charges,90% of total billed charges,6.3,90,
HUMALOG 1000 UNITS (OMNIPOD),,,636,RC,J1815,HCPCS,outpatient,200,UN,318,190.80,,190.8,60,,152.64,percent of total billed charges,60% of total billed charges,152.64,48,,122.112,percent of total billed charges,48% of total billed charges,0.96,100,,,fee schedule,100% of bcbs custom fee schedule,0.96,100,,,fee schedule,100% of bcbs custom fee schedule,1.07,111,,,fee schedule,111% of bcbs custom fee schedule,159,50,,127.2,percent of total billed charges,50% of total billed charges,222.6,70,,178.08,percent of total billed charges,70% of total billed charges,154.17,48.48,,123.336,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,154.17,48.48,,123.336,percent of total billed charges,48.48% of total billed charges,222.6,70,,178.08,percent of total billed charges,70% of total billed charges,222.6,70,,178.08,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,154.17,48.48,,123.336,percent of total billed charges,48.48% of total billed charges,286.2,90,,228.96,percent of total billed charges,90% of total billed charges,48.48,286.2,
CEVIMELINE CAP [30 MG],,,259,RC,J8499,HCPCS,outpatient,1,UN,47,28.20,,28.2,60,,22.56,percent of total billed charges,60% of total billed charges,22.56,48,,18.048,percent of total billed charges,48% of total billed charges,23.5,50,,18.8,percent of total billed charges,50% of total billed charges,23.5,50,,18.8,percent of total billed charges,50% of total billed charges,23.5,50,,18.8,percent of total billed charges,50% of total billed charges,23.5,50,,18.8,percent of total billed charges,50% of total billed charges,32.9,70,,26.32,percent of total billed charges,70% of total billed charges,22.79,48.48,,18.232,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,22.79,48.48,,18.232,percent of total billed charges,48.48% of total billed charges,32.9,70,,26.32,percent of total billed charges,70% of total billed charges,32.9,70,,26.32,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,22.79,48.48,,18.232,percent of total billed charges,48.48% of total billed charges,42.3,90,,33.84,percent of total billed charges,90% of total billed charges,22.79,90,
OCREVUS INJ [600 MG],,,636,RC,J2350,HCPCS,outpatient,2,UN,70972,42583.20,,42583.2,60,,34066.56,percent of total billed charges,60% of total billed charges,34066.56,48,,27253.248,percent of total billed charges,48% of total billed charges,55.58,100,,,fee schedule,100% of bcbs custom fee schedule,55.58,100,,,fee schedule,100% of bcbs custom fee schedule,61.69,111,,,fee schedule,111% of bcbs custom fee schedule,35486,50,,28388.8,percent of total billed charges,50% of total billed charges,49680.4,70,,39744.32,percent of total billed charges,70% of total billed charges,34407.23,48.48,,27525.784,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,34407.23,48.48,,27525.784,percent of total billed charges,48.48% of total billed charges,49680.4,70,,39744.32,percent of total billed charges,70% of total billed charges,49680.4,70,,39744.32,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,34407.23,48.48,,27525.784,percent of total billed charges,48.48% of total billed charges,63874.8,90,,51099.84,percent of total billed charges,90% of total billed charges,48.48,63874.8,
DILAUDID 1MG/1ML SYRINGE,,,636,RC,J1171,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
CAPVAXIVE 0.5ML INJ,43701715,CDM,636,RC,90677,HCPCS,outpatient,1,UN,691,414.60,,414.6,60,,331.68,percent of total billed charges,60% of total billed charges,331.68,48,,265.344,percent of total billed charges,48% of total billed charges,345.5,50,,276.4,percent of total billed charges,50% of total billed charges,345.5,50,,276.4,percent of total billed charges,50% of total billed charges,345.5,50,,276.4,percent of total billed charges,50% of total billed charges,345.5,50,,276.4,percent of total billed charges,50% of total billed charges,483.7,70,,386.96,percent of total billed charges,70% of total billed charges,335,48.48,,268,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,335,48.48,,268,percent of total billed charges,48.48% of total billed charges,483.7,70,,386.96,percent of total billed charges,70% of total billed charges,483.7,70,,386.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,335,48.48,,268,percent of total billed charges,48.48% of total billed charges,621.9,90,,497.52,percent of total billed charges,90% of total billed charges,48.48,621.9,
MYCAMINE 50 MG IV,,,636,RC,J2248,HCPCS,outpatient,1,UN,116,69.60,,69.6,60,,55.68,percent of total billed charges,60% of total billed charges,55.68,48,,44.544,percent of total billed charges,48% of total billed charges,1.3,100,,,fee schedule,100% of bcbs custom fee schedule,1.3,100,,,fee schedule,100% of bcbs custom fee schedule,1.44,111,,,fee schedule,111% of bcbs custom fee schedule,58,50,,46.4,percent of total billed charges,50% of total billed charges,81.2,70,,64.96,percent of total billed charges,70% of total billed charges,56.24,48.48,,44.992,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,56.24,48.48,,44.992,percent of total billed charges,48.48% of total billed charges,81.2,70,,64.96,percent of total billed charges,70% of total billed charges,81.2,70,,64.96,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,56.24,48.48,,44.992,percent of total billed charges,48.48% of total billed charges,104.4,90,,83.52,percent of total billed charges,90% of total billed charges,48.48,104.4,
TRIFLURIDINE 1% OPTH,,,259,RC,J3490,HCPCS,outpatient,1,UN,940,564.00,,564,60,,451.2,percent of total billed charges,60% of total billed charges,451.2,48,,360.96,percent of total billed charges,48% of total billed charges,470,50,,376,percent of total billed charges,50% of total billed charges,470,50,,376,percent of total billed charges,50% of total billed charges,470,50,,376,percent of total billed charges,50% of total billed charges,470,50,,376,percent of total billed charges,50% of total billed charges,658,70,,526.4,percent of total billed charges,70% of total billed charges,455.71,48.48,,364.568,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,455.71,48.48,,364.568,percent of total billed charges,48.48% of total billed charges,658,70,,526.4,percent of total billed charges,70% of total billed charges,658,70,,526.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,455.71,48.48,,364.568,percent of total billed charges,48.48% of total billed charges,846,90,,676.8,percent of total billed charges,90% of total billed charges,48.48,846,
IVF- SOD CL 0.9% 250 ML,,,258,RC,J7050,HCPCS,outpatient,1,UN,24,14.40,,14.4,60,,11.52,percent of total billed charges,60% of total billed charges,11.52,48,,9.216,percent of total billed charges,48% of total billed charges,0.69,100,,,fee schedule,100% of bcbs custom fee schedule,0.69,100,,,fee schedule,100% of bcbs custom fee schedule,0.77,111,,,fee schedule,111% of bcbs custom fee schedule,12,50,,9.6,percent of total billed charges,50% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,21.6,90,,17.28,percent of total billed charges,90% of total billed charges,11.64,90,
IVF- SOD CL 0.9% 50 ML,,,258,RC,J7050,HCPCS,outpatient,1,UN,24,14.40,,14.4,60,,11.52,percent of total billed charges,60% of total billed charges,11.52,48,,9.216,percent of total billed charges,48% of total billed charges,0.69,100,,,fee schedule,100% of bcbs custom fee schedule,0.69,100,,,fee schedule,100% of bcbs custom fee schedule,0.77,111,,,fee schedule,111% of bcbs custom fee schedule,12,50,,9.6,percent of total billed charges,50% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,21.6,90,,17.28,percent of total billed charges,90% of total billed charges,11.64,90,
IVF- SOD CL 0.9% 1000 ML,36000020,CDM,258,RC,J7030,HCPCS,outpatient,1,UN,24,14.40,,14.4,60,,11.52,percent of total billed charges,60% of total billed charges,11.52,48,,9.216,percent of total billed charges,48% of total billed charges,2.79,100,,,fee schedule,100% of bcbs custom fee schedule,2.79,100,,,fee schedule,100% of bcbs custom fee schedule,3.1,111,,,fee schedule,111% of bcbs custom fee schedule,12,50,,9.6,percent of total billed charges,50% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,21.6,90,,17.28,percent of total billed charges,90% of total billed charges,11.64,90,
IVF- SOD CL 0.45% 1000 ML,36000020,CDM,258,RC,J7030,HCPCS,outpatient,1,UN,32,19.20,,19.2,60,,15.36,percent of total billed charges,60% of total billed charges,15.36,48,,12.288,percent of total billed charges,48% of total billed charges,2.79,100,,,fee schedule,100% of bcbs custom fee schedule,2.79,100,,,fee schedule,100% of bcbs custom fee schedule,3.1,111,,,fee schedule,111% of bcbs custom fee schedule,16,50,,12.8,percent of total billed charges,50% of total billed charges,22.4,70,,17.92,percent of total billed charges,70% of total billed charges,15.51,48.48,,12.408,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,15.51,48.48,,12.408,percent of total billed charges,48.48% of total billed charges,22.4,70,,17.92,percent of total billed charges,70% of total billed charges,22.4,70,,17.92,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,15.51,48.48,,12.408,percent of total billed charges,48.48% of total billed charges,28.8,90,,23.04,percent of total billed charges,90% of total billed charges,15.51,90,
IVF- SOD CL 0.9% 100 ML,,,258,RC,J7050,HCPCS,outpatient,1,UN,15,9.00,,9,60,,7.2,percent of total billed charges,60% of total billed charges,7.2,48,,5.76,percent of total billed charges,48% of total billed charges,0.69,100,,,fee schedule,100% of bcbs custom fee schedule,0.69,100,,,fee schedule,100% of bcbs custom fee schedule,0.77,111,,,fee schedule,111% of bcbs custom fee schedule,7.5,50,,6,percent of total billed charges,50% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,13.5,90,,10.8,percent of total billed charges,90% of total billed charges,7.27,90,
IVF- SOD CL 0.45% 500 ML,36000019,CDM,258,RC,J7040,HCPCS,outpatient,1,UN,29,17.40,,17.4,60,,13.92,percent of total billed charges,60% of total billed charges,13.92,48,,11.136,percent of total billed charges,48% of total billed charges,1.4,100,,,fee schedule,100% of bcbs custom fee schedule,1.4,100,,,fee schedule,100% of bcbs custom fee schedule,1.55,111,,,fee schedule,111% of bcbs custom fee schedule,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,20.3,70,,16.24,percent of total billed charges,70% of total billed charges,14.06,48.48,,11.248,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,14.06,48.48,,11.248,percent of total billed charges,48.48% of total billed charges,20.3,70,,16.24,percent of total billed charges,70% of total billed charges,20.3,70,,16.24,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,14.06,48.48,,11.248,percent of total billed charges,48.48% of total billed charges,26.1,90,,20.88,percent of total billed charges,90% of total billed charges,14.06,90,
IVF- SOD CL 0.9% 500 ML,36000019,CDM,258,RC,J7040,HCPCS,outpatient,1,UN,15,9.00,,9,60,,7.2,percent of total billed charges,60% of total billed charges,7.2,48,,5.76,percent of total billed charges,48% of total billed charges,1.4,100,,,fee schedule,100% of bcbs custom fee schedule,1.4,100,,,fee schedule,100% of bcbs custom fee schedule,1.55,111,,,fee schedule,111% of bcbs custom fee schedule,7.5,50,,6,percent of total billed charges,50% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,13.5,90,,10.8,percent of total billed charges,90% of total billed charges,7.27,90,
IVF- DEXTROSE 5% 50 ML,,,258,RC,J7060,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,2.24,100,,,fee schedule,100% of bcbs custom fee schedule,2.24,100,,,fee schedule,100% of bcbs custom fee schedule,2.49,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
IVF- DEXTROSE 5% 100 ML,,,258,RC,J7060,HCPCS,outpatient,1,UN,15,9.00,,9,60,,7.2,percent of total billed charges,60% of total billed charges,7.2,48,,5.76,percent of total billed charges,48% of total billed charges,2.24,100,,,fee schedule,100% of bcbs custom fee schedule,2.24,100,,,fee schedule,100% of bcbs custom fee schedule,2.49,111,,,fee schedule,111% of bcbs custom fee schedule,7.5,50,,6,percent of total billed charges,50% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,13.5,90,,10.8,percent of total billed charges,90% of total billed charges,7.27,90,
IVF- DEXTROSE 5% 250 ML,,,258,RC,J7060,HCPCS,outpatient,1,UN,23,13.80,,13.8,60,,11.04,percent of total billed charges,60% of total billed charges,11.04,48,,8.832,percent of total billed charges,48% of total billed charges,2.24,100,,,fee schedule,100% of bcbs custom fee schedule,2.24,100,,,fee schedule,100% of bcbs custom fee schedule,2.49,111,,,fee schedule,111% of bcbs custom fee schedule,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,16.1,70,,12.88,percent of total billed charges,70% of total billed charges,11.15,48.48,,8.92,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,11.15,48.48,,8.92,percent of total billed charges,48.48% of total billed charges,16.1,70,,12.88,percent of total billed charges,70% of total billed charges,16.1,70,,12.88,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,11.15,48.48,,8.92,percent of total billed charges,48.48% of total billed charges,20.7,90,,16.56,percent of total billed charges,90% of total billed charges,11.15,90,
IVF- DEXTROSE 5% 500 ML,,,258,RC,J7060,HCPCS,outpatient,1,UN,15,9.00,,9,60,,7.2,percent of total billed charges,60% of total billed charges,7.2,48,,5.76,percent of total billed charges,48% of total billed charges,2.24,100,,,fee schedule,100% of bcbs custom fee schedule,2.24,100,,,fee schedule,100% of bcbs custom fee schedule,2.49,111,,,fee schedule,111% of bcbs custom fee schedule,7.5,50,,6,percent of total billed charges,50% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,13.5,90,,10.8,percent of total billed charges,90% of total billed charges,7.27,90,
IVF- DEXTROSE 5% 1000 ML,,,258,RC,J7060,HCPCS,outpatient,1,UN,15,9.00,,9,60,,7.2,percent of total billed charges,60% of total billed charges,7.2,48,,5.76,percent of total billed charges,48% of total billed charges,2.24,100,,,fee schedule,100% of bcbs custom fee schedule,2.24,100,,,fee schedule,100% of bcbs custom fee schedule,2.49,111,,,fee schedule,111% of bcbs custom fee schedule,7.5,50,,6,percent of total billed charges,50% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,13.5,90,,10.8,percent of total billed charges,90% of total billed charges,7.27,90,
IVF- DEX 5%/ 0.2% SOD CL,,,258,RC,J7042,HCPCS,outpatient,1,UN,28,16.80,,16.8,60,,13.44,percent of total billed charges,60% of total billed charges,13.44,48,,10.752,percent of total billed charges,48% of total billed charges,1.19,100,,,fee schedule,100% of bcbs custom fee schedule,1.19,100,,,fee schedule,100% of bcbs custom fee schedule,1.32,111,,,fee schedule,111% of bcbs custom fee schedule,14,50,,11.2,percent of total billed charges,50% of total billed charges,19.6,70,,15.68,percent of total billed charges,70% of total billed charges,13.57,48.48,,10.856,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,13.57,48.48,,10.856,percent of total billed charges,48.48% of total billed charges,19.6,70,,15.68,percent of total billed charges,70% of total billed charges,19.6,70,,15.68,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,13.57,48.48,,10.856,percent of total billed charges,48.48% of total billed charges,25.2,90,,20.16,percent of total billed charges,90% of total billed charges,13.57,90,
IVF- DEX 5%/0.45% SOD CL,,,258,RC,J7042,HCPCS,outpatient,1,UN,15,9.00,,9,60,,7.2,percent of total billed charges,60% of total billed charges,7.2,48,,5.76,percent of total billed charges,48% of total billed charges,1.19,100,,,fee schedule,100% of bcbs custom fee schedule,1.19,100,,,fee schedule,100% of bcbs custom fee schedule,1.32,111,,,fee schedule,111% of bcbs custom fee schedule,7.5,50,,6,percent of total billed charges,50% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,13.5,90,,10.8,percent of total billed charges,90% of total billed charges,7.27,90,
IVF- DEX 5%/ 0.9% SOD CL,,,258,RC,J7042,HCPCS,outpatient,1,UN,15,9.00,,9,60,,7.2,percent of total billed charges,60% of total billed charges,7.2,48,,5.76,percent of total billed charges,48% of total billed charges,1.19,100,,,fee schedule,100% of bcbs custom fee schedule,1.19,100,,,fee schedule,100% of bcbs custom fee schedule,1.32,111,,,fee schedule,111% of bcbs custom fee schedule,7.5,50,,6,percent of total billed charges,50% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,13.5,90,,10.8,percent of total billed charges,90% of total billed charges,7.27,90,
POT CL/NACL 0.45% PREMIX,,,250,RC,J3480,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,0.17,100,,,fee schedule,100% of bcbs custom fee schedule,0.17,100,,,fee schedule,100% of bcbs custom fee schedule,0.19,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
POT CL/ NACL 0.9% PREMIX,,,250,RC,J3480,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,0.17,100,,,fee schedule,100% of bcbs custom fee schedule,0.17,100,,,fee schedule,100% of bcbs custom fee schedule,0.19,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
POT CL/ NACL 0.9% PREMIX,,,250,RC,J3480,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,0.17,100,,,fee schedule,100% of bcbs custom fee schedule,0.17,100,,,fee schedule,100% of bcbs custom fee schedule,0.19,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
POT CL/ D51/2NACL PREMIX,,,250,RC,J3480,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,0.17,100,,,fee schedule,100% of bcbs custom fee schedule,0.17,100,,,fee schedule,100% of bcbs custom fee schedule,0.19,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
IVF- SOD CL 3% 500 ML,,,258,RC,J7130,HCPCS,outpatient,1,UN,21,12.60,,12.6,60,,10.08,percent of total billed charges,60% of total billed charges,10.08,48,,8.064,percent of total billed charges,48% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,14.7,70,,11.76,percent of total billed charges,70% of total billed charges,10.18,48.48,,8.144,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,10.18,48.48,,8.144,percent of total billed charges,48.48% of total billed charges,14.7,70,,11.76,percent of total billed charges,70% of total billed charges,14.7,70,,11.76,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,10.18,48.48,,8.144,percent of total billed charges,48.48% of total billed charges,18.9,90,,15.12,percent of total billed charges,90% of total billed charges,10.18,90,
IVF- LACTATED RINGERS 100,,,258,RC,J7120,HCPCS,outpatient,1,UN,15,9.00,,9,60,,7.2,percent of total billed charges,60% of total billed charges,7.2,48,,5.76,percent of total billed charges,48% of total billed charges,2.57,100,,,fee schedule,100% of bcbs custom fee schedule,2.57,100,,,fee schedule,100% of bcbs custom fee schedule,2.85,111,,,fee schedule,111% of bcbs custom fee schedule,7.5,50,,6,percent of total billed charges,50% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,10.5,70,,8.4,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,7.27,48.48,,5.816,percent of total billed charges,48.48% of total billed charges,13.5,90,,10.8,percent of total billed charges,90% of total billed charges,7.27,90,
POT CL/ D5/0.9%NACL PREMI,,,250,RC,J3480,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,0.17,100,,,fee schedule,100% of bcbs custom fee schedule,0.17,100,,,fee schedule,100% of bcbs custom fee schedule,0.19,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
IVF- DEX 5%/ 0.45% SOD CL,,,258,RC,J7042,HCPCS,outpatient,1,UN,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,1.19,100,,,fee schedule,100% of bcbs custom fee schedule,1.19,100,,,fee schedule,100% of bcbs custom fee schedule,1.32,111,,,fee schedule,111% of bcbs custom fee schedule,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
CO-ENZYME Q10 200 mg (45CT),,,257,RC,A9150,HCPCS,outpatient,1,UN,67,40.20,,40.2,60,,32.16,percent of total billed charges,60% of total billed charges,32.16,48,,25.728,percent of total billed charges,48% of total billed charges,33.5,50,,26.8,percent of total billed charges,50% of total billed charges,33.5,50,,26.8,percent of total billed charges,50% of total billed charges,33.5,50,,26.8,percent of total billed charges,50% of total billed charges,33.5,50,,26.8,percent of total billed charges,50% of total billed charges,46.9,70,,37.52,percent of total billed charges,70% of total billed charges,32.48,48.48,,25.984,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,32.48,48.48,,25.984,percent of total billed charges,48.48% of total billed charges,46.9,70,,37.52,percent of total billed charges,70% of total billed charges,46.9,70,,37.52,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,32.48,48.48,,25.984,percent of total billed charges,48.48% of total billed charges,60.3,90,,48.24,percent of total billed charges,90% of total billed charges,32.48,90,
IVF- DEX 5%/ 0.2% SOD CHL 1000 ML,,,258,RC,,,outpatient,,,20,12.00,,12,60,,9.6,percent of total billed charges,60% of total billed charges,9.6,48,,7.68,percent of total billed charges,48% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,14,70,,11.2,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,9.7,48.48,,7.76,percent of total billed charges,48.48% of total billed charges,18,90,,14.4,percent of total billed charges,90% of total billed charges,9.7,90,
IVF-D10W 500 ML,,,258,RC,,,outpatient,,,24,14.40,,14.4,60,,11.52,percent of total billed charges,60% of total billed charges,11.52,48,,9.216,percent of total billed charges,48% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,21.6,90,,17.28,percent of total billed charges,90% of total billed charges,11.64,90,
IVF- SOD CL 0.9% 150 ML,,,258,RC,,,outpatient,,,26,15.60,,15.6,60,,12.48,percent of total billed charges,60% of total billed charges,12.48,48,,9.984,percent of total billed charges,48% of total billed charges,13,50,,10.4,percent of total billed charges,50% of total billed charges,13,50,,10.4,percent of total billed charges,50% of total billed charges,13,50,,10.4,percent of total billed charges,50% of total billed charges,13,50,,10.4,percent of total billed charges,50% of total billed charges,18.2,70,,14.56,percent of total billed charges,70% of total billed charges,12.6,48.48,,10.08,percent of total billed charges,48.48% of total billed charges,12.6,48.48,,10.08,percent of total billed charges,48.48% of total billed charges,12.6,48.48,,10.08,percent of total billed charges,48.48% of total billed charges,18.2,70,,14.56,percent of total billed charges,70% of total billed charges,18.2,70,,14.56,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,12.6,48.48,,10.08,percent of total billed charges,48.48% of total billed charges,23.4,90,,18.72,percent of total billed charges,90% of total billed charges,12.6,90,
SOD CHL 0.95 250 ML (FOR KCL 40MEQ),,,258,RC,,,outpatient,,,24,14.40,,14.4,60,,11.52,percent of total billed charges,60% of total billed charges,11.52,48,,9.216,percent of total billed charges,48% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,16.8,70,,13.44,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,11.64,48.48,,9.312,percent of total billed charges,48.48% of total billed charges,21.6,90,,17.28,percent of total billed charges,90% of total billed charges,11.64,90,
CEFTAZIDIME INJ 1 GM,,,636,RC,J0713,HCPCS,outpatient,1,UN,25,15.00,,15,60,,12,percent of total billed charges,60% of total billed charges,12,48,,9.6,percent of total billed charges,48% of total billed charges,2.15,100,,,fee schedule,100% of bcbs custom fee schedule,2.15,100,,,fee schedule,100% of bcbs custom fee schedule,2.39,111,,,fee schedule,111% of bcbs custom fee schedule,12.5,50,,10,percent of total billed charges,50% of total billed charges,17.5,70,,14,percent of total billed charges,70% of total billed charges,12.12,48.48,,9.696,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,12.12,48.48,,9.696,percent of total billed charges,48.48% of total billed charges,17.5,70,,14,percent of total billed charges,70% of total billed charges,17.5,70,,14,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,12.12,48.48,,9.696,percent of total billed charges,48.48% of total billed charges,22.5,90,,18,percent of total billed charges,90% of total billed charges,12.12,90,
COVID-19 1ST ADMINISTRATION PFIZER,,,771,RC,0001A,HCPCS,outpatient,,,44,26.40,,26.4,60,,21.12,percent of total billed charges,60% of total billed charges,21.12,48,,16.896,percent of total billed charges,48% of total billed charges,20.35,100,,,fee schedule,100% of bcbs custom fee schedule,20.35,100,,,fee schedule,100% of bcbs custom fee schedule,22.59,111,,,fee schedule,111% of bcbs custom fee schedule,22,50,,17.6,percent of total billed charges,50% of total billed charges,30.8,70,,24.64,percent of total billed charges,70% of total billed charges,21.33,48.48,,17.064,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,21.33,48.48,,17.064,percent of total billed charges,48.48% of total billed charges,30.8,70,,24.64,percent of total billed charges,70% of total billed charges,30.8,70,,24.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,21.33,48.48,,17.064,percent of total billed charges,48.48% of total billed charges,39.6,90,,31.68,percent of total billed charges,90% of total billed charges,21.33,90,
COVID-19 2ND ADMINISTRATION PFIZER,,,771,RC,0002A,HCPCS,outpatient,,,44,26.40,,26.4,60,,21.12,percent of total billed charges,60% of total billed charges,21.12,48,,16.896,percent of total billed charges,48% of total billed charges,28.39,100,,,fee schedule,100% of bcbs custom fee schedule,28.39,100,,,fee schedule,100% of bcbs custom fee schedule,31.51,111,,,fee schedule,111% of bcbs custom fee schedule,22,50,,17.6,percent of total billed charges,50% of total billed charges,30.8,70,,24.64,percent of total billed charges,70% of total billed charges,21.33,48.48,,17.064,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,21.33,48.48,,17.064,percent of total billed charges,48.48% of total billed charges,30.8,70,,24.64,percent of total billed charges,70% of total billed charges,30.8,70,,24.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,21.33,48.48,,17.064,percent of total billed charges,48.48% of total billed charges,39.6,90,,31.68,percent of total billed charges,90% of total billed charges,21.33,90,
COVID-19 ADMINISTRATION - JANSSEN,,,771,RC,0031A,HCPCS,outpatient,,,44,26.40,,26.4,60,,21.12,percent of total billed charges,60% of total billed charges,21.12,48,,16.896,percent of total billed charges,48% of total billed charges,28.39,100,,,fee schedule,100% of bcbs custom fee schedule,28.39,100,,,fee schedule,100% of bcbs custom fee schedule,31.51,111,,,fee schedule,111% of bcbs custom fee schedule,22,50,,17.6,percent of total billed charges,50% of total billed charges,30.8,70,,24.64,percent of total billed charges,70% of total billed charges,21.33,48.48,,17.064,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,21.33,48.48,,17.064,percent of total billed charges,48.48% of total billed charges,30.8,70,,24.64,percent of total billed charges,70% of total billed charges,30.8,70,,24.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,21.33,48.48,,17.064,percent of total billed charges,48.48% of total billed charges,39.6,90,,31.68,percent of total billed charges,90% of total billed charges,21.33,90,
COVID-19 3RD ADMINISTRATION PFIZER,,,771,RC,0003A,HCPCS,outpatient,,,44,26.40,,26.4,60,,21.12,percent of total billed charges,60% of total billed charges,21.12,48,,16.896,percent of total billed charges,48% of total billed charges,22,50,,17.6,percent of total billed charges,50% of total billed charges,22,50,,17.6,percent of total billed charges,50% of total billed charges,22,50,,17.6,percent of total billed charges,50% of total billed charges,22,50,,17.6,percent of total billed charges,50% of total billed charges,30.8,70,,24.64,percent of total billed charges,70% of total billed charges,21.33,48.48,,17.064,percent of total billed charges,48.48% of total billed charges,,,,,other,not separately reimbusable,21.33,48.48,,17.064,percent of total billed charges,48.48% of total billed charges,30.8,70,,24.64,percent of total billed charges,70% of total billed charges,30.8,70,,24.64,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,21.33,48.48,,17.064,percent of total billed charges,48.48% of total billed charges,39.6,90,,31.68,percent of total billed charges,90% of total billed charges,21.33,90,
PF CT CERVICAL SPINE W CONTRAST,42003060,CDM,972,RC,72126,HCPCS,outpatient,,,253,151.80,,,,,,other,not separately reimbusable,157.08,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,147.82,100,,,fee schedule,100% of cigna custom fee schedule,172.79,110,,,fee schedule,110% of cms physician fee schedule,158.65,101,,,fee schedule,101% of cms physician fee schedule ,158.65,116.15,,,fee schedule,116.51% of cms physician fee schedule,158.65,101,,,fee schedule,101% of cms physician fee schedule,298.45,110,,,fee schedule,110% of humana physician fee schedule,172.79,110,,,fee schedule,110% of humana physician fee schedule,235.62,150,,,fee schedule,100% of cms fee schedule,157.08,100,,,fee schedule,100% of cms physician fee schedule,235.62,150,,,fee schedule,150% of cms physician fee schedule,100,235.62,
PF CT CERVICAL SPINE W/WO CONTRAST,42003050,CDM,972,RC,72127,HCPCS,outpatient,,,314,188.40,,,,,,other,not separately reimbusable,183.33,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,174.04,100,,,fee schedule,100% of cigna custom fee schedule,201.66,110,,,fee schedule,110% of cms physician fee schedule,185.16,101,,,fee schedule,101% of cms physician fee schedule ,185.16,116.15,,,fee schedule,116.51% of cms physician fee schedule,185.16,101,,,fee schedule,101% of cms physician fee schedule,348.33,110,,,fee schedule,110% of humana physician fee schedule,201.66,110,,,fee schedule,110% of humana physician fee schedule,275,150,,,fee schedule,100% of cms fee schedule,183.33,100,,,fee schedule,100% of cms physician fee schedule,275,150,,,fee schedule,150% of cms physician fee schedule,100,275,
PF ANKLE BRACHIAL INDEX,43509017,CDM,972,RC,93922,HCPCS,outpatient,,,120,72.00,,,,,,other,not separately reimbusable,73.5,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,82.99,100,,,fee schedule,100% of cigna custom fee schedule,80.85,110,,,fee schedule,110% of cms physician fee schedule,74.24,101,,,fee schedule,101% of cms physician fee schedule ,74.24,116.15,,,fee schedule,116.51% of cms physician fee schedule,74.24,101,,,fee schedule,101% of cms physician fee schedule,139.65,110,,,fee schedule,110% of humana physician fee schedule,80.85,110,,,fee schedule,110% of humana physician fee schedule,110.25,150,,,fee schedule,100% of cms fee schedule,73.5,100,,,fee schedule,100% of cms physician fee schedule,110.25,150,,,fee schedule,150% of cms physician fee schedule,73.5,150,
PF CT LOWER EXT W/WO CONTRAST,42003171,CDM,972,RC,73702,HCPCS,outpatient,,,302,181.20,,,,,,other,not separately reimbusable,181,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,176.35,100,,,fee schedule,100% of cigna custom fee schedule,199.1,110,,,fee schedule,110% of cms physician fee schedule,182.81,101,,,fee schedule,101% of cms physician fee schedule ,182.81,116.15,,,fee schedule,116.51% of cms physician fee schedule,182.81,101,,,fee schedule,101% of cms physician fee schedule,343.9,110,,,fee schedule,110% of humana physician fee schedule,199.1,110,,,fee schedule,110% of humana physician fee schedule,271.5,150,,,fee schedule,100% of cms fee schedule,181,100,,,fee schedule,100% of cms physician fee schedule,271.5,150,,,fee schedule,150% of cms physician fee schedule,100,271.5,
PF CT LOWER EXT W CONTRAST,42003181,CDM,975,RC,73701,HCPCS,outpatient,,,211,126.60,,,,,,other,not separately reimbusable,155.09,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,146.09,100,,,fee schedule,100% of cigna custom fee schedule,170.6,110,,,fee schedule,110% of cms physician fee schedule,156.64,101,,,fee schedule,101% of cms physician fee schedule ,156.64,116.15,,,fee schedule,116.51% of cms physician fee schedule,156.64,101,,,fee schedule,101% of cms physician fee schedule,294.67,110,,,fee schedule,110% of humana physician fee schedule,170.6,110,,,fee schedule,110% of humana physician fee schedule,232.64,150,,,fee schedule,100% of cms fee schedule,155.09,100,,,fee schedule,100% of cms physician fee schedule,232.64,150,,,fee schedule,150% of cms physician fee schedule,100,232.64,
PF CT UPPER EXT W/WO CONT,42003391,CDM,972,RC,73202,HCPCS,outpatient,,,247,148.20,,,,,,other,not separately reimbusable,229.11,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,178.35,100,,,fee schedule,100% of cigna custom fee schedule,252.02,110,,,fee schedule,110% of cms physician fee schedule,231.4,101,,,fee schedule,101% of cms physician fee schedule ,231.4,116.15,,,fee schedule,116.51% of cms physician fee schedule,231.4,101,,,fee schedule,101% of cms physician fee schedule,435.31,110,,,fee schedule,110% of humana physician fee schedule,252.02,110,,,fee schedule,110% of humana physician fee schedule,343.67,150,,,fee schedule,100% of cms fee schedule,229.11,100,,,fee schedule,100% of cms physician fee schedule,343.67,150,,,fee schedule,150% of cms physician fee schedule,100,343.67,
PF CT UPPER EXT W CONTRAST,42003401,CDM,972,RC,73201,HCPCS,outpatient,,,247,148.20,,,,,,other,not separately reimbusable,185.7,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,143.87,100,,,fee schedule,100% of cigna custom fee schedule,204.27,110,,,fee schedule,110% of cms physician fee schedule,187.56,101,,,fee schedule,101% of cms physician fee schedule ,187.56,116.15,,,fee schedule,116.51% of cms physician fee schedule,187.56,101,,,fee schedule,101% of cms physician fee schedule,352.83,110,,,fee schedule,110% of humana physician fee schedule,204.27,110,,,fee schedule,110% of humana physician fee schedule,278.55,150,,,fee schedule,100% of cms fee schedule,185.7,100,,,fee schedule,100% of cms physician fee schedule,278.55,150,,,fee schedule,150% of cms physician fee schedule,100,278.55,
PF UPPER EXT(INFANT) 2 VW,42000851,CDM,972,RC,73092,HCPCS,outpatient,,,31,18.60,26,,,,,other,not separately reimbusable,28.54,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,17.99,100,,,fee schedule,100% of cigna custom fee schedule,31.39,110,,,fee schedule,110% of cms physician fee schedule,28.83,101,,,fee schedule,101% of cms physician fee schedule ,28.83,116.15,,,fee schedule,116.51% of cms physician fee schedule,28.83,101,,,fee schedule,101% of cms physician fee schedule,54.23,110,,,fee schedule,110% of humana physician fee schedule,31.39,110,,,fee schedule,110% of humana physician fee schedule,42.81,150,,,fee schedule,100% of cms fee schedule,28.54,100,,,fee schedule,100% of cms physician fee schedule,42.81,150,,,fee schedule,150% of cms physician fee schedule,28.54,150,
PF RIBS BILAT 4V W/ PA CHEST,42000685,CDM,972,RC,71111,HCPCS,outpatient,,,42,25.20,26,,,,,other,not separately reimbusable,42,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,31.45,100,,,fee schedule,100% of cigna custom fee schedule,46.2,110,,,fee schedule,110% of cms physician fee schedule,42.42,101,,,fee schedule,101% of cms physician fee schedule ,42.42,116.15,,,fee schedule,116.51% of cms physician fee schedule,42.42,101,,,fee schedule,101% of cms physician fee schedule,79.8,110,,,fee schedule,110% of humana physician fee schedule,46.2,110,,,fee schedule,110% of humana physician fee schedule,63,150,,,fee schedule,100% of cms fee schedule,42,100,,,fee schedule,100% of cms physician fee schedule,63,150,,,fee schedule,150% of cms physician fee schedule,42,150,
PF MANDIBLE MIN 4 VIEWS,42000490,CDM,972,RC,70110,HCPCS,outpatient,,,62,37.20,26,,,,,other,not separately reimbusable,39.4,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,24.71,100,,,fee schedule,100% of cigna custom fee schedule,43.34,110,,,fee schedule,110% of cms physician fee schedule,39.79,101,,,fee schedule,101% of cms physician fee schedule ,39.79,116.15,,,fee schedule,116.51% of cms physician fee schedule,39.79,101,,,fee schedule,101% of cms physician fee schedule,74.86,110,,,fee schedule,110% of humana physician fee schedule,43.34,110,,,fee schedule,110% of humana physician fee schedule,59.1,150,,,fee schedule,100% of cms fee schedule,39.4,100,,,fee schedule,100% of cms physician fee schedule,59.1,150,,,fee schedule,150% of cms physician fee schedule,39.4,150,
PF MANDIBLE LESS THAN 4 VIEWS,,,972,RC,70100,HCPCS,outpatient,,,43,25.80,26,,,,,other,not separately reimbusable,35.03,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,21.39,100,,,fee schedule,100% of cigna custom fee schedule,38.53,110,,,fee schedule,110% of cms physician fee schedule,35.38,101,,,fee schedule,101% of cms physician fee schedule ,35.38,116.15,,,fee schedule,116.51% of cms physician fee schedule,35.38,101,,,fee schedule,101% of cms physician fee schedule,66.56,110,,,fee schedule,110% of humana physician fee schedule,38.53,110,,,fee schedule,110% of humana physician fee schedule,52.55,150,,,fee schedule,100% of cms fee schedule,35.03,100,,,fee schedule,100% of cms physician fee schedule,52.55,150,,,fee schedule,150% of cms physician fee schedule,35.03,150,
PF FACIAL BONES 3 VIEWS,42000295,CDM,972,RC,70150,HCPCS,outpatient,,,66,39.60,26,,,,,other,not separately reimbusable,42.65,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,26.97,100,,,fee schedule,100% of cigna custom fee schedule,46.92,110,,,fee schedule,110% of cms physician fee schedule,43.08,101,,,fee schedule,101% of cms physician fee schedule ,43.08,116.15,,,fee schedule,116.51% of cms physician fee schedule,43.08,101,,,fee schedule,101% of cms physician fee schedule,81.04,110,,,fee schedule,110% of humana physician fee schedule,46.92,110,,,fee schedule,110% of humana physician fee schedule,63.98,150,,,fee schedule,100% of cms fee schedule,42.65,100,,,fee schedule,100% of cms physician fee schedule,63.98,150,,,fee schedule,150% of cms physician fee schedule,42.65,150,
PF MASTOID 3 VIEWS,42000495,CDM,972,RC,70130,HCPCS,outpatient,,,43,25.80,26,,,,,other,not separately reimbusable,43,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,35.52,100,,,fee schedule,100% of cigna custom fee schedule,47.3,110,,,fee schedule,110% of cms physician fee schedule,43.43,101,,,fee schedule,101% of cms physician fee schedule ,43.43,116.15,,,fee schedule,116.51% of cms physician fee schedule,43.43,101,,,fee schedule,101% of cms physician fee schedule,81.7,110,,,fee schedule,110% of humana physician fee schedule,47.3,110,,,fee schedule,110% of humana physician fee schedule,64.5,150,,,fee schedule,100% of cms fee schedule,43,100,,,fee schedule,100% of cms physician fee schedule,64.5,150,,,fee schedule,150% of cms physician fee schedule,43,150,
PF NASAL BONES 3 VIEWS,42000555,CDM,972,RC,70160,HCPCS,outpatient,,,43,25.80,26,,,,,other,not separately reimbusable,33.83,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,21.14,100,,,fee schedule,100% of cigna custom fee schedule,37.21,110,,,fee schedule,110% of cms physician fee schedule,34.17,101,,,fee schedule,101% of cms physician fee schedule ,34.17,116.15,,,fee schedule,116.51% of cms physician fee schedule,34.17,101,,,fee schedule,101% of cms physician fee schedule,64.28,110,,,fee schedule,110% of humana physician fee schedule,37.21,110,,,fee schedule,110% of humana physician fee schedule,50.75,150,,,fee schedule,100% of cms fee schedule,33.83,100,,,fee schedule,100% of cms physician fee schedule,50.75,150,,,fee schedule,150% of cms physician fee schedule,33.83,150,
PF FACIAL BONES LESS THAN 3 VIEWS,,,972,RC,70140,HCPCS,outpatient,,,48,28.80,26,,,,,other,not separately reimbusable,28.95,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,19.42,100,,,fee schedule,100% of cigna custom fee schedule,31.85,110,,,fee schedule,110% of cms physician fee schedule,29.24,101,,,fee schedule,101% of cms physician fee schedule ,29.24,116.15,,,fee schedule,116.51% of cms physician fee schedule,29.24,101,,,fee schedule,101% of cms physician fee schedule,55.01,110,,,fee schedule,110% of humana physician fee schedule,31.85,110,,,fee schedule,110% of humana physician fee schedule,43.43,150,,,fee schedule,100% of cms fee schedule,28.95,100,,,fee schedule,100% of cms physician fee schedule,43.43,150,,,fee schedule,150% of cms physician fee schedule,28.95,150,
PF SINUSES MIN 3 VIEWS,42000730,CDM,972,RC,70220,HCPCS,outpatient,,,56,33.60,26,,,,,other,not separately reimbusable,34.03,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,24.49,100,,,fee schedule,100% of cigna custom fee schedule,37.43,110,,,fee schedule,110% of cms physician fee schedule,34.37,101,,,fee schedule,101% of cms physician fee schedule ,34.37,116.15,,,fee schedule,116.51% of cms physician fee schedule,34.37,101,,,fee schedule,101% of cms physician fee schedule,64.66,110,,,fee schedule,110% of humana physician fee schedule,37.43,110,,,fee schedule,110% of humana physician fee schedule,51.05,150,,,fee schedule,100% of cms fee schedule,34.03,100,,,fee schedule,100% of cms physician fee schedule,51.05,150,,,fee schedule,150% of cms physician fee schedule,34.03,150,
PF SINUSES LESS THAN 3 VIEWS,,,972,RC,70210,HCPCS,outpatient,,,56,33.60,26,,,,,other,not separately reimbusable,29.16,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,19.36,100,,,fee schedule,100% of cigna custom fee schedule,32.08,110,,,fee schedule,110% of cms physician fee schedule,29.45,101,,,fee schedule,101% of cms physician fee schedule ,29.45,116.15,,,fee schedule,116.51% of cms physician fee schedule,29.45,101,,,fee schedule,101% of cms physician fee schedule,55.4,110,,,fee schedule,110% of humana physician fee schedule,32.08,110,,,fee schedule,110% of humana physician fee schedule,43.74,150,,,fee schedule,100% of cms fee schedule,29.16,100,,,fee schedule,100% of cms physician fee schedule,43.74,150,,,fee schedule,150% of cms physician fee schedule,29.16,150,
PF SKULL SERIES < 4 VIEWS,42000740,CDM,972,RC,70250,HCPCS,outpatient,,,50,30.00,26,,,,,other,not separately reimbusable,32.41,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,23.57,100,,,fee schedule,100% of cigna custom fee schedule,35.65,110,,,fee schedule,110% of cms physician fee schedule,32.73,101,,,fee schedule,101% of cms physician fee schedule ,32.73,116.15,,,fee schedule,116.51% of cms physician fee schedule,32.73,101,,,fee schedule,101% of cms physician fee schedule,61.58,110,,,fee schedule,110% of humana physician fee schedule,35.65,110,,,fee schedule,110% of humana physician fee schedule,48.62,150,,,fee schedule,100% of cms fee schedule,32.41,100,,,fee schedule,100% of cms physician fee schedule,48.62,150,,,fee schedule,150% of cms physician fee schedule,32.41,150,
PF NECK SOFT TISSUE,42000560,CDM,972,RC,70360,HCPCS,outpatient,,,45,27.00,26,,,,,other,not separately reimbusable,28.33,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,18.24,100,,,fee schedule,100% of cigna custom fee schedule,31.16,110,,,fee schedule,110% of cms physician fee schedule,28.61,101,,,fee schedule,101% of cms physician fee schedule ,28.61,116.15,,,fee schedule,116.51% of cms physician fee schedule,28.61,101,,,fee schedule,101% of cms physician fee schedule,53.83,110,,,fee schedule,110% of humana physician fee schedule,31.16,110,,,fee schedule,110% of humana physician fee schedule,42.5,150,,,fee schedule,100% of cms fee schedule,28.33,100,,,fee schedule,100% of cms physician fee schedule,42.5,150,,,fee schedule,150% of cms physician fee schedule,28.33,150,
PF TMJ UNILATERAL,,,972,RC,70328,HCPCS,outpatient,,,48,28.80,26,,,,,other,not separately reimbusable,31.24,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,19.83,100,,,fee schedule,100% of cigna custom fee schedule,34.36,110,,,fee schedule,110% of cms physician fee schedule,31.55,101,,,fee schedule,101% of cms physician fee schedule ,31.55,116.15,,,fee schedule,116.51% of cms physician fee schedule,31.55,101,,,fee schedule,101% of cms physician fee schedule,59.36,110,,,fee schedule,110% of humana physician fee schedule,34.36,110,,,fee schedule,110% of humana physician fee schedule,46.86,150,,,fee schedule,100% of cms fee schedule,31.24,100,,,fee schedule,100% of cms physician fee schedule,46.86,150,,,fee schedule,150% of cms physician fee schedule,31.24,150,
PF CT HEAD/ BRAIN WO CONTRAST,42003110,CDM,972,RC,70450,HCPCS,outpatient,,,211,126.60,26,,,,,other,not separately reimbusable,99.01,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,75.98,100,,,fee schedule,100% of cigna custom fee schedule,108.91,110,,,fee schedule,110% of cms physician fee schedule,100,101,,,fee schedule,101% of cms physician fee schedule ,100,116.15,,,fee schedule,116.51% of cms physician fee schedule,100,101,,,fee schedule,101% of cms physician fee schedule,188.12,110,,,fee schedule,110% of humana physician fee schedule,108.91,110,,,fee schedule,110% of humana physician fee schedule,148.52,150,,,fee schedule,100% of cms fee schedule,99.01,100,,,fee schedule,100% of cms physician fee schedule,148.52,150,,,fee schedule,150% of cms physician fee schedule,99.01,150,
PF SKULL SERIES 4 VIEWS MIN,42000745,CDM,972,RC,70260,HCPCS,outpatient,,,36,21.60,26,,,,,other,not separately reimbusable,36,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,29.95,100,,,fee schedule,100% of cigna custom fee schedule,39.6,110,,,fee schedule,110% of cms physician fee schedule,36.36,101,,,fee schedule,101% of cms physician fee schedule ,36.36,116.15,,,fee schedule,116.51% of cms physician fee schedule,36.36,101,,,fee schedule,101% of cms physician fee schedule,68.4,110,,,fee schedule,110% of humana physician fee schedule,39.6,110,,,fee schedule,110% of humana physician fee schedule,54,150,,,fee schedule,100% of cms fee schedule,36,100,,,fee schedule,100% of cms physician fee schedule,54,150,,,fee schedule,150% of cms physician fee schedule,36,150,
PF CT MAXILLOFACIALW/O CONTRAST,42003240,CDM,972,RC,70486,HCPCS,outpatient,,,213,127.80,26,,,,,other,not separately reimbusable,118.84,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,90.46,100,,,fee schedule,100% of cigna custom fee schedule,130.72,110,,,fee schedule,110% of cms physician fee schedule,120.03,101,,,fee schedule,101% of cms physician fee schedule ,120.03,116.15,,,fee schedule,116.51% of cms physician fee schedule,120.03,101,,,fee schedule,101% of cms physician fee schedule,225.8,110,,,fee schedule,110% of humana physician fee schedule,130.72,110,,,fee schedule,110% of humana physician fee schedule,178.26,150,,,fee schedule,100% of cms fee schedule,118.84,100,,,fee schedule,100% of cms physician fee schedule,178.26,150,,,fee schedule,150% of cms physician fee schedule,100,178.26,
PF ORBIT 4 VIEWS,42000605,CDM,972,RC,70200,HCPCS,outpatient,,,43,25.80,26,,,,,other,not separately reimbusable,43,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,27.47,100,,,fee schedule,100% of cigna custom fee schedule,47.3,110,,,fee schedule,110% of cms physician fee schedule,43.43,101,,,fee schedule,101% of cms physician fee schedule ,43.43,116.15,,,fee schedule,116.51% of cms physician fee schedule,43.43,101,,,fee schedule,101% of cms physician fee schedule,81.7,110,,,fee schedule,110% of humana physician fee schedule,47.3,110,,,fee schedule,110% of humana physician fee schedule,64.5,150,,,fee schedule,100% of cms fee schedule,43,100,,,fee schedule,100% of cms physician fee schedule,64.5,150,,,fee schedule,150% of cms physician fee schedule,43,150,
PF CT SOFT TISSUE NECK W/O CONTRAST,42003350,CDM,972,RC,70490,HCPCS,outpatient,,,316,189.60,26,,,,,other,not separately reimbusable,140.42,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,125.71,100,,,fee schedule,100% of cigna custom fee schedule,154.46,110,,,fee schedule,110% of cms physician fee schedule,141.82,101,,,fee schedule,101% of cms physician fee schedule ,141.82,116.15,,,fee schedule,116.51% of cms physician fee schedule,141.82,101,,,fee schedule,101% of cms physician fee schedule,266.8,110,,,fee schedule,110% of humana physician fee schedule,154.46,110,,,fee schedule,110% of humana physician fee schedule,210.63,150,,,fee schedule,100% of cms fee schedule,140.42,100,,,fee schedule,100% of cms physician fee schedule,210.63,150,,,fee schedule,150% of cms physician fee schedule,100,210.63,
PF CT HEAD/BRAIN W/WO CNTRST,42003130,CDM,972,RC,70470,HCPCS,outpatient,,,302,181.20,,,,,,other,not separately reimbusable,161.75,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,125.01,100,,,fee schedule,100% of cigna custom fee schedule,177.93,110,,,fee schedule,110% of cms physician fee schedule,163.37,101,,,fee schedule,101% of cms physician fee schedule ,163.37,116.15,,,fee schedule,116.51% of cms physician fee schedule,163.37,101,,,fee schedule,101% of cms physician fee schedule,307.33,110,,,fee schedule,110% of humana physician fee schedule,177.93,110,,,fee schedule,110% of humana physician fee schedule,242.63,150,,,fee schedule,100% of cms fee schedule,161.75,100,,,fee schedule,100% of cms physician fee schedule,242.63,150,,,fee schedule,150% of cms physician fee schedule,100,242.63,
PF CHEST 1 VIEW,42000165,CDM,972,RC,71045,HCPCS,outpatient,,,45,27.00,26,,,,,other,not separately reimbusable,23.37,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,13.15,100,,,fee schedule,100% of cigna custom fee schedule,25.71,110,,,fee schedule,110% of cms physician fee schedule,23.6,101,,,fee schedule,101% of cms physician fee schedule ,23.6,116.15,,,fee schedule,116.51% of cms physician fee schedule,23.6,101,,,fee schedule,101% of cms physician fee schedule,44.4,110,,,fee schedule,110% of humana physician fee schedule,25.71,110,,,fee schedule,110% of humana physician fee schedule,35.06,150,,,fee schedule,100% of cms fee schedule,23.37,100,,,fee schedule,100% of cms physician fee schedule,35.06,150,,,fee schedule,150% of cms physician fee schedule,23.37,150,
PF CHEST 2 VIEWS PA/LAT,42000170,CDM,972,RC,71046,HCPCS,outpatient,,,54,32.40,26,,,,,other,not separately reimbusable,30.53,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,19.95,100,,,fee schedule,100% of cigna custom fee schedule,33.58,110,,,fee schedule,110% of cms physician fee schedule,30.84,101,,,fee schedule,101% of cms physician fee schedule ,30.84,116.15,,,fee schedule,116.51% of cms physician fee schedule,30.84,101,,,fee schedule,101% of cms physician fee schedule,58.01,110,,,fee schedule,110% of humana physician fee schedule,33.58,110,,,fee schedule,110% of humana physician fee schedule,45.8,150,,,fee schedule,100% of cms fee schedule,30.53,100,,,fee schedule,100% of cms physician fee schedule,45.8,150,,,fee schedule,150% of cms physician fee schedule,30.53,150,
PF CT MAXILLOFACIAL W CNTRS,42003230,CDM,972,RC,70487,HCPCS,outpatient,,,315,189.00,,,,,,other,not separately reimbusable,141.84,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,109.16,100,,,fee schedule,100% of cigna custom fee schedule,156.02,110,,,fee schedule,110% of cms physician fee schedule,143.26,101,,,fee schedule,101% of cms physician fee schedule ,143.26,116.15,,,fee schedule,116.51% of cms physician fee schedule,143.26,101,,,fee schedule,101% of cms physician fee schedule,269.5,110,,,fee schedule,110% of humana physician fee schedule,156.02,110,,,fee schedule,110% of humana physician fee schedule,212.76,150,,,fee schedule,100% of cms fee schedule,141.84,100,,,fee schedule,100% of cms physician fee schedule,212.76,150,,,fee schedule,150% of cms physician fee schedule,100,212.76,
PF RIBS UNILAT 2 VIEWS,42000676,CDM,972,RC,71100,HCPCS,outpatient,,,56,33.60,26,,,,,other,not separately reimbusable,33.16,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,21.51,100,,,fee schedule,100% of cigna custom fee schedule,36.48,110,,,fee schedule,110% of cms physician fee schedule,33.49,101,,,fee schedule,101% of cms physician fee schedule ,33.49,116.15,,,fee schedule,116.51% of cms physician fee schedule,33.49,101,,,fee schedule,101% of cms physician fee schedule,63,110,,,fee schedule,110% of humana physician fee schedule,36.48,110,,,fee schedule,110% of humana physician fee schedule,49.74,150,,,fee schedule,100% of cms fee schedule,33.16,100,,,fee schedule,100% of cms physician fee schedule,49.74,150,,,fee schedule,150% of cms physician fee schedule,33.16,150,
PF CT MAXILLOFACIAL W/WO CNTRST,42003250,CDM,972,RC,70488,HCPCS,outpatient,,,347,208.20,,,,,,other,not separately reimbusable,171.38,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,132.81,100,,,fee schedule,100% of cigna custom fee schedule,188.52,110,,,fee schedule,110% of cms physician fee schedule,173.09,101,,,fee schedule,101% of cms physician fee schedule ,173.09,116.15,,,fee schedule,116.51% of cms physician fee schedule,173.09,101,,,fee schedule,101% of cms physician fee schedule,325.62,110,,,fee schedule,110% of humana physician fee schedule,188.52,110,,,fee schedule,110% of humana physician fee schedule,257.07,150,,,fee schedule,100% of cms fee schedule,171.38,100,,,fee schedule,100% of cms physician fee schedule,257.07,150,,,fee schedule,150% of cms physician fee schedule,100,257.07,
PF CT THORAX W/O CONTRAST,42003100,CDM,972,RC,71250,HCPCS,outpatient,,,285,171.00,26,,,,,other,not separately reimbusable,124.34,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,117.09,100,,,fee schedule,100% of cigna custom fee schedule,136.77,110,,,fee schedule,110% of cms physician fee schedule,125.58,101,,,fee schedule,101% of cms physician fee schedule ,125.58,116.15,,,fee schedule,116.51% of cms physician fee schedule,125.58,101,,,fee schedule,101% of cms physician fee schedule,236.25,110,,,fee schedule,110% of humana physician fee schedule,136.77,110,,,fee schedule,110% of humana physician fee schedule,186.51,150,,,fee schedule,100% of cms fee schedule,124.34,100,,,fee schedule,100% of cms physician fee schedule,186.51,150,,,fee schedule,150% of cms physician fee schedule,100,186.51,
PF SPINE SINGLE VIEW,42000765,CDM,972,RC,72020,HCPCS,outpatient,,,23,13.80,26,,,,,other,not separately reimbusable,22.12,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,14.4,100,,,fee schedule,100% of cigna custom fee schedule,24.33,110,,,fee schedule,110% of cms physician fee schedule,22.34,101,,,fee schedule,101% of cms physician fee schedule ,22.34,116.15,,,fee schedule,116.51% of cms physician fee schedule,22.34,101,,,fee schedule,101% of cms physician fee schedule,42.03,110,,,fee schedule,110% of humana physician fee schedule,24.33,110,,,fee schedule,110% of humana physician fee schedule,33.18,150,,,fee schedule,100% of cms fee schedule,22.12,100,,,fee schedule,100% of cms physician fee schedule,33.18,150,,,fee schedule,150% of cms physician fee schedule,22.12,150,
PF CT THORAX W CONTRAST,42003090,CDM,972,RC,71260,HCPCS,outpatient,,,308,184.80,26,,,,,other,not separately reimbusable,155.38,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,148.55,100,,,fee schedule,100% of cigna custom fee schedule,170.92,110,,,fee schedule,110% of cms physician fee schedule,156.93,101,,,fee schedule,101% of cms physician fee schedule ,156.93,116.15,,,fee schedule,116.51% of cms physician fee schedule,156.93,101,,,fee schedule,101% of cms physician fee schedule,295.22,110,,,fee schedule,110% of humana physician fee schedule,170.92,110,,,fee schedule,110% of humana physician fee schedule,233.07,150,,,fee schedule,100% of cms fee schedule,155.38,100,,,fee schedule,100% of cms physician fee schedule,233.07,150,,,fee schedule,150% of cms physician fee schedule,100,233.07,
PF CT HEAD/BRAIN W CONTRAST,42003120,CDM,972,RC,70460,HCPCS,outpatient,,,257,154.20,,,,,,other,not separately reimbusable,138.25,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,105.82,100,,,fee schedule,100% of cigna custom fee schedule,152.08,110,,,fee schedule,110% of cms physician fee schedule,139.63,101,,,fee schedule,101% of cms physician fee schedule ,139.63,116.15,,,fee schedule,116.51% of cms physician fee schedule,139.63,101,,,fee schedule,101% of cms physician fee schedule,262.68,110,,,fee schedule,110% of humana physician fee schedule,152.08,110,,,fee schedule,110% of humana physician fee schedule,207.38,150,,,fee schedule,100% of cms fee schedule,138.25,100,,,fee schedule,100% of cms physician fee schedule,207.38,150,,,fee schedule,150% of cms physician fee schedule,100,207.38,
PF CT THORAX W/O & W CONTRAST,42003080,CDM,972,RC,71270,HCPCS,outpatient,,,339,203.40,26,,,,,other,not separately reimbusable,181.99,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,177.55,100,,,fee schedule,100% of cigna custom fee schedule,200.19,110,,,fee schedule,110% of cms physician fee schedule,183.81,101,,,fee schedule,101% of cms physician fee schedule ,183.81,116.15,,,fee schedule,116.51% of cms physician fee schedule,183.81,101,,,fee schedule,101% of cms physician fee schedule,345.78,110,,,fee schedule,110% of humana physician fee schedule,200.19,110,,,fee schedule,110% of humana physician fee schedule,272.99,150,,,fee schedule,100% of cms fee schedule,181.99,100,,,fee schedule,100% of cms physician fee schedule,272.99,150,,,fee schedule,150% of cms physician fee schedule,100,272.99,
PF CT LUMBAR SPINE W CONTRAST,42003210,CDM,972,RC,72132,HCPCS,outpatient,,,300,180.00,,,,,,other,not separately reimbusable,157.38,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,147.6,100,,,fee schedule,100% of cigna custom fee schedule,173.12,110,,,fee schedule,110% of cms physician fee schedule,158.95,101,,,fee schedule,101% of cms physician fee schedule ,158.95,116.15,,,fee schedule,116.51% of cms physician fee schedule,158.95,101,,,fee schedule,101% of cms physician fee schedule,299.02,110,,,fee schedule,110% of humana physician fee schedule,173.12,110,,,fee schedule,110% of humana physician fee schedule,236.07,150,,,fee schedule,100% of cms fee schedule,157.38,100,,,fee schedule,100% of cms physician fee schedule,236.07,150,,,fee schedule,150% of cms physician fee schedule,100,236.07,
PF C-SPINE 2-3 VIEWS,42000240,CDM,972,RC,72040,HCPCS,outpatient,,,56,33.60,26,,,,,other,not separately reimbusable,35.78,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,21.51,100,,,fee schedule,100% of cigna custom fee schedule,39.36,110,,,fee schedule,110% of cms physician fee schedule,36.14,101,,,fee schedule,101% of cms physician fee schedule ,36.14,116.15,,,fee schedule,116.51% of cms physician fee schedule,36.14,101,,,fee schedule,101% of cms physician fee schedule,67.98,110,,,fee schedule,110% of humana physician fee schedule,39.36,110,,,fee schedule,110% of humana physician fee schedule,53.67,150,,,fee schedule,100% of cms fee schedule,35.78,100,,,fee schedule,100% of cms physician fee schedule,53.67,150,,,fee schedule,150% of cms physician fee schedule,35.78,150,
PF CT LUMBAR SPINE W/WO CONTRAST,42003200,CDM,972,RC,72133,HCPCS,outpatient,,,342,205.20,,,,,,other,not separately reimbusable,183.62,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,173.81,100,,,fee schedule,100% of cigna custom fee schedule,201.98,110,,,fee schedule,110% of cms physician fee schedule,185.46,101,,,fee schedule,101% of cms physician fee schedule ,185.46,116.15,,,fee schedule,116.51% of cms physician fee schedule,185.46,101,,,fee schedule,101% of cms physician fee schedule,348.88,110,,,fee schedule,110% of humana physician fee schedule,201.98,110,,,fee schedule,110% of humana physician fee schedule,275.43,150,,,fee schedule,100% of cms fee schedule,183.62,100,,,fee schedule,100% of cms physician fee schedule,275.43,150,,,fee schedule,150% of cms physician fee schedule,100,275.43,
PF C-SPINE MIN 4-5 VIEWS,42000235,CDM,972,RC,72050,HCPCS,outpatient,,,68,40.80,26,,,,,other,not separately reimbusable,48.24,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,29.64,100,,,fee schedule,100% of cigna custom fee schedule,53.06,110,,,fee schedule,110% of cms physician fee schedule,48.72,101,,,fee schedule,101% of cms physician fee schedule ,48.72,116.15,,,fee schedule,116.51% of cms physician fee schedule,48.72,101,,,fee schedule,101% of cms physician fee schedule,91.66,110,,,fee schedule,110% of humana physician fee schedule,53.06,110,,,fee schedule,110% of humana physician fee schedule,72.36,150,,,fee schedule,100% of cms fee schedule,48.24,100,,,fee schedule,100% of cms physician fee schedule,72.36,150,,,fee schedule,150% of cms physician fee schedule,48.24,150,
PF CT ORB/SEL/PF/EAR W/WO CNTRS,42003140,CDM,972,RC,70482,HCPCS,outpatient,,,368,220.80,,,,,,other,not separately reimbusable,195.29,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,194.09,100,,,fee schedule,100% of cigna custom fee schedule,214.82,110,,,fee schedule,110% of cms physician fee schedule,197.24,101,,,fee schedule,101% of cms physician fee schedule ,197.24,116.15,,,fee schedule,116.51% of cms physician fee schedule,197.24,101,,,fee schedule,101% of cms physician fee schedule,371.05,110,,,fee schedule,110% of humana physician fee schedule,214.82,110,,,fee schedule,110% of humana physician fee schedule,292.94,150,,,fee schedule,100% of cms fee schedule,195.29,100,,,fee schedule,100% of cms physician fee schedule,292.94,150,,,fee schedule,150% of cms physician fee schedule,100,292.94,
PF T-SPINE 2 VIEWS,42000790,CDM,972,RC,72070,HCPCS,outpatient,,,50,30.00,26,,,,,other,not separately reimbusable,29.87,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,22.17,100,,,fee schedule,100% of cigna custom fee schedule,32.86,110,,,fee schedule,110% of cms physician fee schedule,30.17,101,,,fee schedule,101% of cms physician fee schedule ,30.17,116.15,,,fee schedule,116.51% of cms physician fee schedule,30.17,101,,,fee schedule,101% of cms physician fee schedule,56.75,110,,,fee schedule,110% of humana physician fee schedule,32.86,110,,,fee schedule,110% of humana physician fee schedule,44.81,150,,,fee schedule,100% of cms fee schedule,29.87,100,,,fee schedule,100% of cms physician fee schedule,44.81,150,,,fee schedule,150% of cms physician fee schedule,29.87,150,
PR ORB/ESL/PF/EAR W CONTRAST,42003150,CDM,972,RC,70481,HCPCS,outpatient,,,325,195.00,,,,,,other,not separately reimbusable,167.5,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,177.99,100,,,fee schedule,100% of cigna custom fee schedule,184.25,110,,,fee schedule,110% of cms physician fee schedule,169.18,101,,,fee schedule,101% of cms physician fee schedule ,169.18,116.15,,,fee schedule,116.51% of cms physician fee schedule,169.18,101,,,fee schedule,101% of cms physician fee schedule,318.25,110,,,fee schedule,110% of humana physician fee schedule,184.25,110,,,fee schedule,110% of humana physician fee schedule,251.25,150,,,fee schedule,100% of cms fee schedule,167.5,100,,,fee schedule,100% of cms physician fee schedule,251.25,150,,,fee schedule,150% of cms physician fee schedule,100,251.25,
PF LS-SPINE 2-3 VIEWS,42000455,CDM,972,RC,72100,HCPCS,outpatient,,,56,33.60,26,,,,,other,not separately reimbusable,36.07,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,22.84,100,,,fee schedule,100% of cigna custom fee schedule,39.68,110,,,fee schedule,110% of cms physician fee schedule,36.43,101,,,fee schedule,101% of cms physician fee schedule ,36.43,116.15,,,fee schedule,116.51% of cms physician fee schedule,36.43,101,,,fee schedule,101% of cms physician fee schedule,68.53,110,,,fee schedule,110% of humana physician fee schedule,39.68,110,,,fee schedule,110% of humana physician fee schedule,54.11,150,,,fee schedule,100% of cms fee schedule,36.07,100,,,fee schedule,100% of cms physician fee schedule,54.11,150,,,fee schedule,150% of cms physician fee schedule,36.07,150,
PF CT PELVIS W/WO CONTRAST,42003300,CDM,972,RC,72194,HCPCS,outpatient,,,315,189.00,,,,,,other,not separately reimbusable,232.61,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,167.66,100,,,fee schedule,100% of cigna custom fee schedule,255.87,110,,,fee schedule,110% of cms physician fee schedule,234.94,101,,,fee schedule,101% of cms physician fee schedule ,234.94,116.15,,,fee schedule,116.51% of cms physician fee schedule,234.94,101,,,fee schedule,101% of cms physician fee schedule,441.96,110,,,fee schedule,110% of humana physician fee schedule,255.87,110,,,fee schedule,110% of humana physician fee schedule,348.92,150,,,fee schedule,100% of cms fee schedule,232.61,100,,,fee schedule,100% of cms physician fee schedule,348.92,150,,,fee schedule,150% of cms physician fee schedule,100,348.92,
PF LS-SPINE MIN 4 VIEWS,42000465,CDM,972,RC,72110,HCPCS,outpatient,,,64,38.40,26,,,,,other,not separately reimbusable,46.74,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,31.87,100,,,fee schedule,100% of cigna custom fee schedule,51.41,110,,,fee schedule,110% of cms physician fee schedule,47.21,101,,,fee schedule,101% of cms physician fee schedule ,47.21,116.15,,,fee schedule,116.51% of cms physician fee schedule,47.21,101,,,fee schedule,101% of cms physician fee schedule,88.81,110,,,fee schedule,110% of humana physician fee schedule,51.41,110,,,fee schedule,110% of humana physician fee schedule,70.11,150,,,fee schedule,100% of cms fee schedule,46.74,100,,,fee schedule,100% of cms physician fee schedule,70.11,150,,,fee schedule,150% of cms physician fee schedule,46.74,150,
PF CT PELVIS WITH CONTRAST,42003310,CDM,972,RC,72193,HCPCS,outpatient,,,275,165.00,,,,,,other,not separately reimbusable,211.07,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,146.09,100,,,fee schedule,100% of cigna custom fee schedule,232.18,110,,,fee schedule,110% of cms physician fee schedule,213.18,101,,,fee schedule,101% of cms physician fee schedule ,213.18,116.15,,,fee schedule,116.51% of cms physician fee schedule,213.18,101,,,fee schedule,101% of cms physician fee schedule,401.03,110,,,fee schedule,110% of humana physician fee schedule,232.18,110,,,fee schedule,110% of humana physician fee schedule,316.61,150,,,fee schedule,100% of cms fee schedule,211.07,100,,,fee schedule,100% of cms physician fee schedule,316.61,150,,,fee schedule,150% of cms physician fee schedule,100,316.61,
PF CT CERVICAL SPINE W/O CONTRAST,42003070,CDM,972,RC,72125,HCPCS,outpatient,,,247,148.20,26,,,,,other,not separately reimbusable,121.3,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,119.91,100,,,fee schedule,100% of cigna custom fee schedule,133.43,110,,,fee schedule,110% of cms physician fee schedule,122.51,101,,,fee schedule,101% of cms physician fee schedule ,122.51,116.15,,,fee schedule,116.51% of cms physician fee schedule,122.51,101,,,fee schedule,101% of cms physician fee schedule,230.47,110,,,fee schedule,110% of humana physician fee schedule,133.43,110,,,fee schedule,110% of humana physician fee schedule,181.95,150,,,fee schedule,100% of cms fee schedule,121.3,100,,,fee schedule,100% of cms physician fee schedule,181.95,150,,,fee schedule,150% of cms physician fee schedule,100,181.95,
PF CT THORACIC SPINE W/WO CONTRAST,42003360,CDM,972,RC,72130,HCPCS,outpatient,,,368,220.80,,,,,,other,not separately reimbusable,184.5,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,174.71,100,,,fee schedule,100% of cigna custom fee schedule,202.95,110,,,fee schedule,110% of cms physician fee schedule,186.35,101,,,fee schedule,101% of cms physician fee schedule ,186.35,116.15,,,fee schedule,116.51% of cms physician fee schedule,186.35,101,,,fee schedule,101% of cms physician fee schedule,350.55,110,,,fee schedule,110% of humana physician fee schedule,202.95,110,,,fee schedule,110% of humana physician fee schedule,276.75,150,,,fee schedule,100% of cms fee schedule,184.5,100,,,fee schedule,100% of cms physician fee schedule,276.75,150,,,fee schedule,150% of cms physician fee schedule,100,276.75,
PF CT LUMBAR SPINE W/O CONTRAST,42003220,CDM,972,RC,72131,HCPCS,outpatient,,,247,148.20,26,,,,,other,not separately reimbusable,120.42,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,116.59,100,,,fee schedule,100% of cigna custom fee schedule,132.46,110,,,fee schedule,110% of cms physician fee schedule,121.62,101,,,fee schedule,101% of cms physician fee schedule ,121.62,116.15,,,fee schedule,116.51% of cms physician fee schedule,121.62,101,,,fee schedule,101% of cms physician fee schedule,228.8,110,,,fee schedule,110% of humana physician fee schedule,132.46,110,,,fee schedule,110% of humana physician fee schedule,180.63,150,,,fee schedule,100% of cms fee schedule,120.42,100,,,fee schedule,100% of cms physician fee schedule,180.63,150,,,fee schedule,150% of cms physician fee schedule,100,180.63,
PF CT THORACIC SPINE W CONTRAST,42003370,CDM,972,RC,72129,HCPCS,outpatient,,,315,189.00,,,,,,other,not separately reimbusable,158.34,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,148.49,100,,,fee schedule,100% of cigna custom fee schedule,174.17,110,,,fee schedule,110% of cms physician fee schedule,159.92,101,,,fee schedule,101% of cms physician fee schedule ,159.92,116.15,,,fee schedule,116.51% of cms physician fee schedule,159.92,101,,,fee schedule,101% of cms physician fee schedule,300.85,110,,,fee schedule,110% of humana physician fee schedule,174.17,110,,,fee schedule,110% of humana physician fee schedule,237.51,150,,,fee schedule,100% of cms fee schedule,158.34,100,,,fee schedule,100% of cms physician fee schedule,237.51,150,,,fee schedule,150% of cms physician fee schedule,100,237.51,
PF PELVIS AP VIEW,42000635,CDM,972,RC,72170,HCPCS,outpatient,,,43,25.80,26,,,,,other,not separately reimbusable,25.37,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,20.7,100,,,fee schedule,100% of cigna custom fee schedule,27.91,110,,,fee schedule,110% of cms physician fee schedule,25.62,101,,,fee schedule,101% of cms physician fee schedule ,25.62,116.15,,,fee schedule,116.51% of cms physician fee schedule,25.62,101,,,fee schedule,101% of cms physician fee schedule,48.2,110,,,fee schedule,110% of humana physician fee schedule,27.91,110,,,fee schedule,110% of humana physician fee schedule,38.06,150,,,fee schedule,100% of cms fee schedule,25.37,100,,,fee schedule,100% of cms physician fee schedule,38.06,150,,,fee schedule,150% of cms physician fee schedule,25.37,150,
PF HIPS BILATERAL 3-4 VIEWS,42001070,CDM,972,RC,73522,HCPCS,outpatient,,,56,33.60,26,,,,,other,not separately reimbusable,48.61,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,31.81,100,,,fee schedule,100% of cigna custom fee schedule,53.47,110,,,fee schedule,110% of cms physician fee schedule,49.1,101,,,fee schedule,101% of cms physician fee schedule ,49.1,116.15,,,fee schedule,116.51% of cms physician fee schedule,49.1,101,,,fee schedule,101% of cms physician fee schedule,92.36,110,,,fee schedule,110% of humana physician fee schedule,53.47,110,,,fee schedule,110% of humana physician fee schedule,72.92,150,,,fee schedule,100% of cms fee schedule,48.61,100,,,fee schedule,100% of cms physician fee schedule,72.92,150,,,fee schedule,150% of cms physician fee schedule,48.61,150,
PF CT PELVIS W/O CONTRAST,42003290,CDM,972,RC,72192,HCPCS,outpatient,,,268,160.80,26,,,,,other,not separately reimbusable,124.38,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,95.68,100,,,fee schedule,100% of cigna custom fee schedule,136.82,110,,,fee schedule,110% of cms physician fee schedule,125.62,101,,,fee schedule,101% of cms physician fee schedule ,125.62,116.15,,,fee schedule,116.51% of cms physician fee schedule,125.62,101,,,fee schedule,101% of cms physician fee schedule,236.32,110,,,fee schedule,110% of humana physician fee schedule,136.82,110,,,fee schedule,110% of humana physician fee schedule,186.57,150,,,fee schedule,100% of cms fee schedule,124.38,100,,,fee schedule,100% of cms physician fee schedule,186.57,150,,,fee schedule,150% of cms physician fee schedule,100,186.57,
PF BONE AGE STUDY,42000105,CDM,972,RC,77072,HCPCS,outpatient,,,21,12.60,26,,,,,other,not separately reimbusable,21,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,15.18,100,,,fee schedule,100% of cigna custom fee schedule,23.1,110,,,fee schedule,110% of cms physician fee schedule,21.21,101,,,fee schedule,101% of cms physician fee schedule ,21.21,116.15,,,fee schedule,116.51% of cms physician fee schedule,21.21,101,,,fee schedule,101% of cms physician fee schedule,39.9,110,,,fee schedule,110% of humana physician fee schedule,23.1,110,,,fee schedule,110% of humana physician fee schedule,31.5,150,,,fee schedule,100% of cms fee schedule,21,100,,,fee schedule,100% of cms physician fee schedule,31.5,150,,,fee schedule,150% of cms physician fee schedule,21,150,
PF SACRUM/COCCYX MIN 2VIEW,42000695,CDM,972,RC,72220,HCPCS,outpatient,,,43,25.80,26,,,,,other,not separately reimbusable,29.45,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,18.24,100,,,fee schedule,100% of cigna custom fee schedule,32.4,110,,,fee schedule,110% of cms physician fee schedule,29.74,101,,,fee schedule,101% of cms physician fee schedule ,29.74,116.15,,,fee schedule,116.51% of cms physician fee schedule,29.74,101,,,fee schedule,101% of cms physician fee schedule,55.96,110,,,fee schedule,110% of humana physician fee schedule,32.4,110,,,fee schedule,110% of humana physician fee schedule,44.18,150,,,fee schedule,100% of cms fee schedule,29.45,100,,,fee schedule,100% of cms physician fee schedule,44.18,150,,,fee schedule,150% of cms physician fee schedule,29.45,150,
PF SHUNT SERIES,,,972,RC,75809,HCPCS,outpatient,,,75.75,45.45,26,,,,,other,not separately reimbusable,73.73,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,63.82,100,,,fee schedule,100% of cigna custom fee schedule,81.1,110,,,fee schedule,110% of cms physician fee schedule,74.47,101,,,fee schedule,101% of cms physician fee schedule ,74.47,116.15,,,fee schedule,116.51% of cms physician fee schedule,74.47,101,,,fee schedule,101% of cms physician fee schedule,140.09,110,,,fee schedule,110% of humana physician fee schedule,81.1,110,,,fee schedule,110% of humana physician fee schedule,110.6,150,,,fee schedule,100% of cms fee schedule,73.73,100,,,fee schedule,100% of cms physician fee schedule,110.6,150,,,fee schedule,150% of cms physician fee schedule,73.73,150,
PF SHOULDER ONE VIEW,42000281,CDM,972,RC,73020,HCPCS,outpatient,,,38,22.80,26,,,,,other,not separately reimbusable,19.75,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,15.07,100,,,fee schedule,100% of cigna custom fee schedule,21.73,110,,,fee schedule,110% of cms physician fee schedule,19.95,101,,,fee schedule,101% of cms physician fee schedule ,19.95,116.15,,,fee schedule,116.51% of cms physician fee schedule,19.95,101,,,fee schedule,101% of cms physician fee schedule,37.53,110,,,fee schedule,110% of humana physician fee schedule,21.73,110,,,fee schedule,110% of humana physician fee schedule,29.63,150,,,fee schedule,100% of cms fee schedule,19.75,100,,,fee schedule,100% of cms physician fee schedule,29.63,150,,,fee schedule,150% of cms physician fee schedule,19.75,150,
PF SCREENING MAMMOGRAPHY,42001029,CDM,982,RC,77067,HCPCS,outpatient,,,140,84.00,26,,,,,other,not separately reimbusable,115.55,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,88.34,100,,,fee schedule,100% of cigna custom fee schedule,127.11,110,,,fee schedule,110% of cms physician fee schedule,116.71,101,,,fee schedule,101% of cms physician fee schedule ,116.71,116.15,,,fee schedule,116.51% of cms physician fee schedule,116.71,101,,,fee schedule,101% of cms physician fee schedule,219.55,110,,,fee schedule,110% of humana physician fee schedule,127.11,110,,,fee schedule,110% of humana physician fee schedule,173.33,150,,,fee schedule,100% of cms fee schedule,115.55,100,,,fee schedule,100% of cms physician fee schedule,173.33,150,,,fee schedule,150% of cms physician fee schedule,100,173.33,
PF SHOULDER MIN 2 VIEWS,42000716,CDM,972,RC,73030,HCPCS,outpatient,,,47,28.20,26,,,,,other,not separately reimbusable,31.53,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,18.94,100,,,fee schedule,100% of cigna custom fee schedule,34.68,110,,,fee schedule,110% of cms physician fee schedule,31.85,101,,,fee schedule,101% of cms physician fee schedule ,31.85,116.15,,,fee schedule,116.51% of cms physician fee schedule,31.85,101,,,fee schedule,101% of cms physician fee schedule,59.91,110,,,fee schedule,110% of humana physician fee schedule,34.68,110,,,fee schedule,110% of humana physician fee schedule,47.3,150,,,fee schedule,100% of cms fee schedule,31.53,100,,,fee schedule,100% of cms physician fee schedule,47.3,150,,,fee schedule,150% of cms physician fee schedule,31.53,150,
PF SI JOINTS 3/> VIEWS,42000690,CDM,972,RC,72202,HCPCS,outpatient,,,106.74,64.04,26,,,,,other,not separately reimbusable,35.53,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,21.42,100,,,fee schedule,100% of cigna custom fee schedule,39.08,110,,,fee schedule,110% of cms physician fee schedule,35.89,101,,,fee schedule,101% of cms physician fee schedule ,35.89,116.15,,,fee schedule,116.51% of cms physician fee schedule,35.89,101,,,fee schedule,101% of cms physician fee schedule,67.51,110,,,fee schedule,110% of humana physician fee schedule,39.08,110,,,fee schedule,110% of humana physician fee schedule,53.3,150,,,fee schedule,100% of cms fee schedule,35.53,100,,,fee schedule,100% of cms physician fee schedule,53.3,150,,,fee schedule,150% of cms physician fee schedule,35.53,150,
PF HUMERUS MIN 2 VIEWS,42000381,CDM,972,RC,73060,HCPCS,outpatient,,,42,25.20,26,,,,,other,not separately reimbusable,28.83,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,18.88,100,,,fee schedule,100% of cigna custom fee schedule,31.71,110,,,fee schedule,110% of cms physician fee schedule,29.12,101,,,fee schedule,101% of cms physician fee schedule ,29.12,116.15,,,fee schedule,116.51% of cms physician fee schedule,29.12,101,,,fee schedule,101% of cms physician fee schedule,54.78,110,,,fee schedule,110% of humana physician fee schedule,31.71,110,,,fee schedule,110% of humana physician fee schedule,43.25,150,,,fee schedule,100% of cms fee schedule,28.83,100,,,fee schedule,100% of cms physician fee schedule,43.25,150,,,fee schedule,150% of cms physician fee schedule,28.83,150,
PF ELBOW 2 VIEWS,42000266,CDM,972,RC,73070,HCPCS,outpatient,,,42,25.20,26,,,,,other,not separately reimbusable,26.49,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,17.74,100,,,fee schedule,100% of cigna custom fee schedule,29.14,110,,,fee schedule,110% of cms physician fee schedule,26.75,101,,,fee schedule,101% of cms physician fee schedule ,26.75,116.15,,,fee schedule,116.51% of cms physician fee schedule,26.75,101,,,fee schedule,101% of cms physician fee schedule,50.33,110,,,fee schedule,110% of humana physician fee schedule,29.14,110,,,fee schedule,110% of humana physician fee schedule,39.74,150,,,fee schedule,100% of cms fee schedule,26.49,100,,,fee schedule,100% of cms physician fee schedule,39.74,150,,,fee schedule,150% of cms physician fee schedule,26.49,150,
PF ELBOW COMP 3 VIEWS,42000271,CDM,972,RC,73080,HCPCS,outpatient,,,43,25.80,26,,,,,other,not separately reimbusable,29.74,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,20.25,100,,,fee schedule,100% of cigna custom fee schedule,32.71,110,,,fee schedule,110% of cms physician fee schedule,30.04,101,,,fee schedule,101% of cms physician fee schedule ,30.04,116.15,,,fee schedule,116.51% of cms physician fee schedule,30.04,101,,,fee schedule,101% of cms physician fee schedule,56.51,110,,,fee schedule,110% of humana physician fee schedule,32.71,110,,,fee schedule,110% of humana physician fee schedule,44.61,150,,,fee schedule,100% of cms fee schedule,29.74,100,,,fee schedule,100% of cms physician fee schedule,44.61,150,,,fee schedule,150% of cms physician fee schedule,29.74,150,
PF FOREARM 2 VIEWS,42000346,CDM,972,RC,73090,HCPCS,outpatient,,,42,25.20,26,,,,,other,not separately reimbusable,26.49,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,16.88,100,,,fee schedule,100% of cigna custom fee schedule,29.14,110,,,fee schedule,110% of cms physician fee schedule,26.75,101,,,fee schedule,101% of cms physician fee schedule ,26.75,116.15,,,fee schedule,116.51% of cms physician fee schedule,26.75,101,,,fee schedule,101% of cms physician fee schedule,50.33,110,,,fee schedule,110% of humana physician fee schedule,29.14,110,,,fee schedule,110% of humana physician fee schedule,39.74,150,,,fee schedule,100% of cms fee schedule,26.49,100,,,fee schedule,100% of cms physician fee schedule,39.74,150,,,fee schedule,150% of cms physician fee schedule,26.49,150,
PF WRIST 2 VIEWS,42000886,CDM,972,RC,73100,HCPCS,outpatient,,,42,25.20,26,,,,,other,not separately reimbusable,30.58,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,18.88,100,,,fee schedule,100% of cigna custom fee schedule,33.64,110,,,fee schedule,110% of cms physician fee schedule,30.89,101,,,fee schedule,101% of cms physician fee schedule ,30.89,116.15,,,fee schedule,116.51% of cms physician fee schedule,30.89,101,,,fee schedule,101% of cms physician fee schedule,58.1,110,,,fee schedule,110% of humana physician fee schedule,33.64,110,,,fee schedule,110% of humana physician fee schedule,45.87,150,,,fee schedule,100% of cms fee schedule,30.58,100,,,fee schedule,100% of cms physician fee schedule,45.87,150,,,fee schedule,150% of cms physician fee schedule,30.58,150,
PF WRIST 3 VIEWS,42000892,CDM,972,RC,73110,HCPCS,outpatient,,,43,25.80,26,,,,,other,not separately reimbusable,37.03,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,22.92,100,,,fee schedule,100% of cigna custom fee schedule,40.73,110,,,fee schedule,110% of cms physician fee schedule,37.4,101,,,fee schedule,101% of cms physician fee schedule ,37.4,116.15,,,fee schedule,116.51% of cms physician fee schedule,37.4,101,,,fee schedule,101% of cms physician fee schedule,70.36,110,,,fee schedule,110% of humana physician fee schedule,40.73,110,,,fee schedule,110% of humana physician fee schedule,55.55,150,,,fee schedule,100% of cms fee schedule,37.03,100,,,fee schedule,100% of cms physician fee schedule,55.55,150,,,fee schedule,150% of cms physician fee schedule,37.03,150,
PF HAND 2 VIEWS,42000356,CDM,972,RC,73120,HCPCS,outpatient,,,42,25.20,26,,,,,other,not separately reimbusable,28.54,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,17.1,100,,,fee schedule,100% of cigna custom fee schedule,31.39,110,,,fee schedule,110% of cms physician fee schedule,28.83,101,,,fee schedule,101% of cms physician fee schedule ,28.83,116.15,,,fee schedule,116.51% of cms physician fee schedule,28.83,101,,,fee schedule,101% of cms physician fee schedule,54.23,110,,,fee schedule,110% of humana physician fee schedule,31.39,110,,,fee schedule,110% of humana physician fee schedule,42.81,150,,,fee schedule,100% of cms fee schedule,28.54,100,,,fee schedule,100% of cms physician fee schedule,42.81,150,,,fee schedule,150% of cms physician fee schedule,28.54,150,
PF HAND 3 VIEWS,42000361,CDM,972,RC,73130,HCPCS,outpatient,,,43,25.80,26,,,,,other,not separately reimbusable,33.53,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,20.03,100,,,fee schedule,100% of cigna custom fee schedule,36.88,110,,,fee schedule,110% of cms physician fee schedule,33.87,101,,,fee schedule,101% of cms physician fee schedule ,33.87,116.15,,,fee schedule,116.51% of cms physician fee schedule,33.87,101,,,fee schedule,101% of cms physician fee schedule,63.71,110,,,fee schedule,110% of humana physician fee schedule,36.88,110,,,fee schedule,110% of humana physician fee schedule,50.3,150,,,fee schedule,100% of cms fee schedule,33.53,100,,,fee schedule,100% of cms physician fee schedule,50.3,150,,,fee schedule,150% of cms physician fee schedule,33.53,150,
PF FINGER 2 VIEW,42000910,CDM,972,RC,73140,HCPCS,outpatient,,,35,21.00,26,,,,,other,not separately reimbusable,34.24,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,20.36,100,,,fee schedule,100% of cigna custom fee schedule,37.66,110,,,fee schedule,110% of cms physician fee schedule,34.58,101,,,fee schedule,101% of cms physician fee schedule ,34.58,116.15,,,fee schedule,116.51% of cms physician fee schedule,34.58,101,,,fee schedule,101% of cms physician fee schedule,65.06,110,,,fee schedule,110% of humana physician fee schedule,37.66,110,,,fee schedule,110% of humana physician fee schedule,51.36,150,,,fee schedule,100% of cms fee schedule,34.24,100,,,fee schedule,100% of cms physician fee schedule,51.36,150,,,fee schedule,150% of cms physician fee schedule,34.24,150,
PF HIP UNILAT 1 VIEW,42001063,CDM,972,RC,73501,HCPCS,outpatient,,,47,28.20,26,,,,,other,not separately reimbusable,29.78,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,19.39,100,,,fee schedule,100% of cigna custom fee schedule,32.76,110,,,fee schedule,110% of cms physician fee schedule,30.08,101,,,fee schedule,101% of cms physician fee schedule ,30.08,116.15,,,fee schedule,116.51% of cms physician fee schedule,30.08,101,,,fee schedule,101% of cms physician fee schedule,56.58,110,,,fee schedule,110% of humana physician fee schedule,32.76,110,,,fee schedule,110% of humana physician fee schedule,44.67,150,,,fee schedule,100% of cms fee schedule,29.78,100,,,fee schedule,100% of cms physician fee schedule,44.67,150,,,fee schedule,150% of cms physician fee schedule,29.78,150,
PF HIP UNILAT 2 VIEWS,42001065,CDM,972,RC,73502,HCPCS,outpatient,,,56,33.60,26,,,,,other,not separately reimbusable,42.78,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,26.85,100,,,fee schedule,100% of cigna custom fee schedule,47.06,110,,,fee schedule,110% of cms physician fee schedule,43.21,101,,,fee schedule,101% of cms physician fee schedule ,43.21,116.15,,,fee schedule,116.51% of cms physician fee schedule,43.21,101,,,fee schedule,101% of cms physician fee schedule,81.28,110,,,fee schedule,110% of humana physician fee schedule,47.06,110,,,fee schedule,110% of humana physician fee schedule,64.17,150,,,fee schedule,100% of cms fee schedule,42.78,100,,,fee schedule,100% of cms physician fee schedule,64.17,150,,,fee schedule,150% of cms physician fee schedule,42.78,150,
PF HIP BILAT W/ AP PELVIS 2 VIEWS,42001069,CDM,972,RC,73521,HCPCS,outpatient,,,56,33.60,26,,,,,other,not separately reimbusable,37.24,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,25.74,100,,,fee schedule,100% of cigna custom fee schedule,40.96,110,,,fee schedule,110% of cms physician fee schedule,37.61,101,,,fee schedule,101% of cms physician fee schedule ,37.61,116.15,,,fee schedule,116.51% of cms physician fee schedule,37.61,101,,,fee schedule,101% of cms physician fee schedule,70.76,110,,,fee schedule,110% of humana physician fee schedule,40.96,110,,,fee schedule,110% of humana physician fee schedule,55.86,150,,,fee schedule,100% of cms fee schedule,37.24,100,,,fee schedule,100% of cms physician fee schedule,55.86,150,,,fee schedule,150% of cms physician fee schedule,37.24,150,
PF FEMUR AP/LAT,42000301,CDM,972,RC,73552,HCPCS,outpatient,,,45,27.00,26,,,,,other,not separately reimbusable,32.12,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,21.17,100,,,fee schedule,100% of cigna custom fee schedule,35.33,110,,,fee schedule,110% of cms physician fee schedule,32.44,101,,,fee schedule,101% of cms physician fee schedule ,32.44,116.15,,,fee schedule,116.51% of cms physician fee schedule,32.44,101,,,fee schedule,101% of cms physician fee schedule,61.03,110,,,fee schedule,110% of humana physician fee schedule,35.33,110,,,fee schedule,110% of humana physician fee schedule,48.18,150,,,fee schedule,100% of cms fee schedule,32.12,100,,,fee schedule,100% of cms physician fee schedule,48.18,150,,,fee schedule,150% of cms physician fee schedule,32.12,150,
PF KNEE AP/LAT,42000431,CDM,972,RC,73560,HCPCS,outpatient,,,42,25.20,26,,,,,other,not separately reimbusable,30.87,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,20,100,,,fee schedule,100% of cigna custom fee schedule,33.96,110,,,fee schedule,110% of cms physician fee schedule,31.18,101,,,fee schedule,101% of cms physician fee schedule ,31.18,116.15,,,fee schedule,116.51% of cms physician fee schedule,31.18,101,,,fee schedule,101% of cms physician fee schedule,58.65,110,,,fee schedule,110% of humana physician fee schedule,33.96,110,,,fee schedule,110% of humana physician fee schedule,46.31,150,,,fee schedule,100% of cms fee schedule,30.87,100,,,fee schedule,100% of cms physician fee schedule,46.31,150,,,fee schedule,150% of cms physician fee schedule,30.87,150,
PF KNEE 3 VIEW,42000441,CDM,972,RC,73562,HCPCS,outpatient,,,47,28.20,26,,,,,other,not separately reimbusable,36.78,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,23.18,100,,,fee schedule,100% of cigna custom fee schedule,40.46,110,,,fee schedule,110% of cms physician fee schedule,37.15,101,,,fee schedule,101% of cms physician fee schedule ,37.15,116.15,,,fee schedule,116.51% of cms physician fee schedule,37.15,101,,,fee schedule,101% of cms physician fee schedule,69.88,110,,,fee schedule,110% of humana physician fee schedule,40.46,110,,,fee schedule,110% of humana physician fee schedule,55.17,150,,,fee schedule,100% of cms fee schedule,36.78,100,,,fee schedule,100% of cms physician fee schedule,55.17,150,,,fee schedule,150% of cms physician fee schedule,36.78,150,
PF TIB/FIB 2 VIEWS,42000801,CDM,972,RC,73590,HCPCS,outpatient,,,40,24.00,26,,,,,other,not separately reimbusable,28.54,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,18.66,100,,,fee schedule,100% of cigna custom fee schedule,31.39,110,,,fee schedule,110% of cms physician fee schedule,28.83,101,,,fee schedule,101% of cms physician fee schedule ,28.83,116.15,,,fee schedule,116.51% of cms physician fee schedule,28.83,101,,,fee schedule,101% of cms physician fee schedule,54.23,110,,,fee schedule,110% of humana physician fee schedule,31.39,110,,,fee schedule,110% of humana physician fee schedule,42.81,150,,,fee schedule,100% of cms fee schedule,28.54,100,,,fee schedule,100% of cms physician fee schedule,42.81,150,,,fee schedule,150% of cms physician fee schedule,28.54,150,
PF ANKLE 2 VIEWS,42000031,CDM,972,RC,73600,HCPCS,outpatient,,,42,25.20,26,,,,,other,not separately reimbusable,29.12,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,19.33,100,,,fee schedule,100% of cigna custom fee schedule,32.03,110,,,fee schedule,110% of cms physician fee schedule,29.41,101,,,fee schedule,101% of cms physician fee schedule ,29.41,116.15,,,fee schedule,116.51% of cms physician fee schedule,29.41,101,,,fee schedule,101% of cms physician fee schedule,55.33,110,,,fee schedule,110% of humana physician fee schedule,32.03,110,,,fee schedule,110% of humana physician fee schedule,43.68,150,,,fee schedule,100% of cms fee schedule,29.12,100,,,fee schedule,100% of cms physician fee schedule,43.68,150,,,fee schedule,150% of cms physician fee schedule,29.12,150,
PF ANKLE 3 VIEWS,42000036,CDM,972,RC,73610,HCPCS,outpatient,,,43,25.80,26,,,,,other,not separately reimbusable,32.95,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,20.47,100,,,fee schedule,100% of cigna custom fee schedule,36.25,110,,,fee schedule,110% of cms physician fee schedule,33.28,101,,,fee schedule,101% of cms physician fee schedule ,33.28,116.15,,,fee schedule,116.51% of cms physician fee schedule,33.28,101,,,fee schedule,101% of cms physician fee schedule,62.61,110,,,fee schedule,110% of humana physician fee schedule,36.25,110,,,fee schedule,110% of humana physician fee schedule,49.43,150,,,fee schedule,100% of cms fee schedule,32.95,100,,,fee schedule,100% of cms physician fee schedule,49.43,150,,,fee schedule,150% of cms physician fee schedule,32.95,150,
PF FOOT 2 VIEWS,42000341,CDM,972,RC,73620,HCPCS,outpatient,,,39,23.40,26,,,,,other,not separately reimbusable,25.91,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,16.88,100,,,fee schedule,100% of cigna custom fee schedule,28.5,110,,,fee schedule,110% of cms physician fee schedule,26.17,101,,,fee schedule,101% of cms physician fee schedule ,26.17,116.15,,,fee schedule,116.51% of cms physician fee schedule,26.17,101,,,fee schedule,101% of cms physician fee schedule,49.23,110,,,fee schedule,110% of humana physician fee schedule,28.5,110,,,fee schedule,110% of humana physician fee schedule,38.87,150,,,fee schedule,100% of cms fee schedule,25.91,100,,,fee schedule,100% of cms physician fee schedule,38.87,150,,,fee schedule,150% of cms physician fee schedule,25.91,150,
PF FOOT 3 VIEWS,42000336,CDM,972,RC,73630,HCPCS,outpatient,,,42,25.20,26,,,,,other,not separately reimbusable,30.91,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,18.91,100,,,fee schedule,100% of cigna custom fee schedule,34,110,,,fee schedule,110% of cms physician fee schedule,31.22,101,,,fee schedule,101% of cms physician fee schedule ,31.22,116.15,,,fee schedule,116.51% of cms physician fee schedule,31.22,101,,,fee schedule,101% of cms physician fee schedule,58.73,110,,,fee schedule,110% of humana physician fee schedule,34,110,,,fee schedule,110% of humana physician fee schedule,46.37,150,,,fee schedule,100% of cms fee schedule,30.91,100,,,fee schedule,100% of cms physician fee schedule,46.37,150,,,fee schedule,150% of cms physician fee schedule,30.91,150,
PF TOES 2 VIEWS,42000970,CDM,972,RC,73660,HCPCS,outpatient,,,33,19.80,26,,,,,other,not separately reimbusable,26.37,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,18.13,100,,,fee schedule,100% of cigna custom fee schedule,29.01,110,,,fee schedule,110% of cms physician fee schedule,26.63,101,,,fee schedule,101% of cms physician fee schedule ,26.63,116.15,,,fee schedule,116.51% of cms physician fee schedule,26.63,101,,,fee schedule,101% of cms physician fee schedule,50.1,110,,,fee schedule,110% of humana physician fee schedule,29.01,110,,,fee schedule,110% of humana physician fee schedule,39.56,150,,,fee schedule,100% of cms fee schedule,26.37,100,,,fee schedule,100% of cms physician fee schedule,39.56,150,,,fee schedule,150% of cms physician fee schedule,26.37,150,
PF CT LOWER EXT W/O CONTRAST,42003191,CDM,972,RC,73700,HCPCS,outpatient,,,247,148.20,26,,,,,other,not separately reimbusable,120.71,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,116.59,100,,,fee schedule,100% of cigna custom fee schedule,132.78,110,,,fee schedule,110% of cms physician fee schedule,121.92,101,,,fee schedule,101% of cms physician fee schedule ,121.92,116.15,,,fee schedule,116.51% of cms physician fee schedule,121.92,101,,,fee schedule,101% of cms physician fee schedule,229.35,110,,,fee schedule,110% of humana physician fee schedule,132.78,110,,,fee schedule,110% of humana physician fee schedule,181.07,150,,,fee schedule,100% of cms fee schedule,120.71,100,,,fee schedule,100% of cms physician fee schedule,181.07,150,,,fee schedule,150% of cms physician fee schedule,100,181.07,
PF CT NECK SOFT TISS WO/W CNTR,42003330,CDM,972,RC,70492,HCPCS,outpatient,,,247,148.20,,,,,,other,not separately reimbusable,205.86,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,179.53,100,,,fee schedule,100% of cigna custom fee schedule,226.45,110,,,fee schedule,110% of cms physician fee schedule,207.92,101,,,fee schedule,101% of cms physician fee schedule ,207.92,116.15,,,fee schedule,116.51% of cms physician fee schedule,207.92,101,,,fee schedule,101% of cms physician fee schedule,391.13,110,,,fee schedule,110% of humana physician fee schedule,226.45,110,,,fee schedule,110% of humana physician fee schedule,308.79,150,,,fee schedule,100% of cms fee schedule,205.86,100,,,fee schedule,100% of cms physician fee schedule,308.79,150,,,fee schedule,150% of cms physician fee schedule,100,308.79,
PF ABD 1 VIEW,42000010,CDM,972,RC,74018,HCPCS,outpatient,,,45,27.00,26,,,,,other,not separately reimbusable,27.45,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,17.83,100,,,fee schedule,100% of cigna custom fee schedule,30.2,110,,,fee schedule,110% of cms physician fee schedule,27.72,101,,,fee schedule,101% of cms physician fee schedule ,27.72,116.15,,,fee schedule,116.51% of cms physician fee schedule,27.72,101,,,fee schedule,101% of cms physician fee schedule,52.16,110,,,fee schedule,110% of humana physician fee schedule,30.2,110,,,fee schedule,110% of humana physician fee schedule,41.18,150,,,fee schedule,100% of cms fee schedule,27.45,100,,,fee schedule,100% of cms physician fee schedule,41.18,150,,,fee schedule,150% of cms physician fee schedule,27.45,150,
PF ABD 2V  FLAT/ERECT COMPLETE,42000016,CDM,972,RC,74021,HCPCS,outpatient,,,66,39.60,26,,,,,other,not separately reimbusable,38.9,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,25.52,100,,,fee schedule,100% of cigna custom fee schedule,42.79,110,,,fee schedule,110% of cms physician fee schedule,39.29,101,,,fee schedule,101% of cms physician fee schedule ,39.29,116.15,,,fee schedule,116.51% of cms physician fee schedule,39.29,101,,,fee schedule,101% of cms physician fee schedule,73.91,110,,,fee schedule,110% of humana physician fee schedule,42.79,110,,,fee schedule,110% of humana physician fee schedule,58.35,150,,,fee schedule,100% of cms fee schedule,38.9,100,,,fee schedule,100% of cms physician fee schedule,58.35,150,,,fee schedule,150% of cms physician fee schedule,38.9,150,
PF ABD SERIES COMPLETE,42000025,CDM,972,RC,74022,HCPCS,outpatient,,,78,46.80,26,,,,,other,not separately reimbusable,45.32,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,29.22,100,,,fee schedule,100% of cigna custom fee schedule,49.85,110,,,fee schedule,110% of cms physician fee schedule,45.77,101,,,fee schedule,101% of cms physician fee schedule ,45.77,116.15,,,fee schedule,116.51% of cms physician fee schedule,45.77,101,,,fee schedule,101% of cms physician fee schedule,86.11,110,,,fee schedule,110% of humana physician fee schedule,49.85,110,,,fee schedule,110% of humana physician fee schedule,67.98,150,,,fee schedule,100% of cms fee schedule,45.32,100,,,fee schedule,100% of cms physician fee schedule,67.98,150,,,fee schedule,150% of cms physician fee schedule,45.32,150,
PF CT ABDOMEN W/O CONTRAST,42003040,CDM,972,RC,74150,HCPCS,outpatient,,,294,176.40,26,,,,,other,not separately reimbusable,128,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,98.27,100,,,fee schedule,100% of cigna custom fee schedule,140.8,110,,,fee schedule,110% of cms physician fee schedule,129.28,101,,,fee schedule,101% of cms physician fee schedule ,129.28,116.15,,,fee schedule,116.51% of cms physician fee schedule,129.28,101,,,fee schedule,101% of cms physician fee schedule,243.2,110,,,fee schedule,110% of humana physician fee schedule,140.8,110,,,fee schedule,110% of humana physician fee schedule,192,150,,,fee schedule,100% of cms fee schedule,128,100,,,fee schedule,100% of cms physician fee schedule,192,150,,,fee schedule,150% of cms physician fee schedule,100,192,
PF CT ABDOMEN W CONTRAST,42003030,CDM,972,RC,74160,HCPCS,outpatient,,,315,189.00,26,,,,,other,not separately reimbusable,215.41,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,149.53,100,,,fee schedule,100% of cigna custom fee schedule,236.95,110,,,fee schedule,110% of cms physician fee schedule,217.56,101,,,fee schedule,101% of cms physician fee schedule ,217.56,116.15,,,fee schedule,116.51% of cms physician fee schedule,217.56,101,,,fee schedule,101% of cms physician fee schedule,409.28,110,,,fee schedule,110% of humana physician fee schedule,236.95,110,,,fee schedule,110% of humana physician fee schedule,323.12,150,,,fee schedule,100% of cms fee schedule,215.41,100,,,fee schedule,100% of cms physician fee schedule,323.12,150,,,fee schedule,150% of cms physician fee schedule,100,323.12,
PF CT ABDOMEN W/WO CONTRAST,42003020,CDM,972,RC,74170,HCPCS,outpatient,,,347,208.20,26,,,,,other,not separately reimbusable,241.9,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,169.81,100,,,fee schedule,100% of cigna custom fee schedule,266.09,110,,,fee schedule,110% of cms physician fee schedule,244.32,101,,,fee schedule,101% of cms physician fee schedule ,244.32,116.15,,,fee schedule,116.51% of cms physician fee schedule,244.32,101,,,fee schedule,101% of cms physician fee schedule,459.61,110,,,fee schedule,110% of humana physician fee schedule,266.09,110,,,fee schedule,110% of humana physician fee schedule,362.85,150,,,fee schedule,100% of cms fee schedule,241.9,100,,,fee schedule,100% of cms physician fee schedule,362.85,150,,,fee schedule,150% of cms physician fee schedule,100,362.85,
PF CT ABDOMEN/PELVIS WO CONTRAST,42030100,CDM,972,RC,74176,HCPCS,outpatient,,,430,258.00,26,,,,,other,not separately reimbusable,172.33,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,132.38,100,,,fee schedule,100% of cigna custom fee schedule,189.56,110,,,fee schedule,110% of cms physician fee schedule,174.05,101,,,fee schedule,101% of cms physician fee schedule ,174.05,116.15,,,fee schedule,116.51% of cms physician fee schedule,174.05,101,,,fee schedule,101% of cms physician fee schedule,327.43,110,,,fee schedule,110% of humana physician fee schedule,189.56,110,,,fee schedule,110% of humana physician fee schedule,258.5,150,,,fee schedule,100% of cms fee schedule,172.33,100,,,fee schedule,100% of cms physician fee schedule,258.5,150,,,fee schedule,150% of cms physician fee schedule,100,258.5,
PF CT ABDOMEN/PELVIS WITH CONTRAST,42030300,CDM,972,RC,74177,HCPCS,outpatient,,,450,270.00,26,,,,,other,not separately reimbusable,280.84,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,201.91,100,,,fee schedule,100% of cigna custom fee schedule,308.92,110,,,fee schedule,110% of cms physician fee schedule,283.65,101,,,fee schedule,101% of cms physician fee schedule ,283.65,116.15,,,fee schedule,116.51% of cms physician fee schedule,283.65,101,,,fee schedule,101% of cms physician fee schedule,533.6,110,,,fee schedule,110% of humana physician fee schedule,308.92,110,,,fee schedule,110% of humana physician fee schedule,421.26,150,,,fee schedule,100% of cms fee schedule,280.84,100,,,fee schedule,100% of cms physician fee schedule,421.26,150,,,fee schedule,150% of cms physician fee schedule,100,421.26,
PF CT ABDOMEN/PELVIS W/WO,42030200,CDM,972,RC,74178,HCPCS,outpatient,,,494,296.40,26,,,,,other,not separately reimbusable,315.05,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,229.12,100,,,fee schedule,100% of cigna custom fee schedule,346.56,110,,,fee schedule,110% of cms physician fee schedule,318.2,101,,,fee schedule,101% of cms physician fee schedule ,318.2,116.15,,,fee schedule,116.51% of cms physician fee schedule,318.2,101,,,fee schedule,101% of cms physician fee schedule,598.6,110,,,fee schedule,110% of humana physician fee schedule,346.56,110,,,fee schedule,110% of humana physician fee schedule,472.58,150,,,fee schedule,100% of cms fee schedule,315.05,100,,,fee schedule,100% of cms physician fee schedule,472.58,150,,,fee schedule,150% of cms physician fee schedule,100,472.58,
PF US SOFT TISSUES HEAD NECK THYROID,42002220,CDM,972,RC,76536,HCPCS,outpatient,,,139,83.40,26,,,,,other,not separately reimbusable,99.18,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,75.66,100,,,fee schedule,100% of cigna custom fee schedule,109.1,110,,,fee schedule,110% of cms physician fee schedule,100.17,101,,,fee schedule,101% of cms physician fee schedule ,100.17,116.15,,,fee schedule,116.51% of cms physician fee schedule,100.17,101,,,fee schedule,101% of cms physician fee schedule,188.44,110,,,fee schedule,110% of humana physician fee schedule,109.1,110,,,fee schedule,110% of humana physician fee schedule,148.77,150,,,fee schedule,100% of cms fee schedule,99.18,100,,,fee schedule,100% of cms physician fee schedule,148.77,150,,,fee schedule,150% of cms physician fee schedule,99.18,150,
PF US CHEST,36000029,CDM,972,RC,76604,HCPCS,outpatient,,,143,85.80,26,,,,,other,not separately reimbusable,52.65,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,57.81,100,,,fee schedule,100% of cigna custom fee schedule,57.92,110,,,fee schedule,110% of cms physician fee schedule,53.18,101,,,fee schedule,101% of cms physician fee schedule ,53.18,116.15,,,fee schedule,116.51% of cms physician fee schedule,53.18,101,,,fee schedule,101% of cms physician fee schedule,100.04,110,,,fee schedule,110% of humana physician fee schedule,57.92,110,,,fee schedule,110% of humana physician fee schedule,78.98,150,,,fee schedule,100% of cms fee schedule,52.65,100,,,fee schedule,100% of cms physician fee schedule,78.98,150,,,fee schedule,150% of cms physician fee schedule,52.65,150,
PF US BREAST COMPLETE,42001081,CDM,972,RC,76641,HCPCS,outpatient,,,179,107.40,26,,,,,other,not separately reimbusable,93.27,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,70.43,100,,,fee schedule,100% of cigna custom fee schedule,102.6,110,,,fee schedule,110% of cms physician fee schedule,94.2,101,,,fee schedule,101% of cms physician fee schedule ,94.2,116.15,,,fee schedule,116.51% of cms physician fee schedule,94.2,101,,,fee schedule,101% of cms physician fee schedule,177.21,110,,,fee schedule,110% of humana physician fee schedule,102.6,110,,,fee schedule,110% of humana physician fee schedule,139.91,150,,,fee schedule,100% of cms fee schedule,93.27,100,,,fee schedule,100% of cms physician fee schedule,139.91,150,,,fee schedule,150% of cms physician fee schedule,93.27,150,
PF US BREAST LIMITED UNILAT,42001083,CDM,972,RC,76642,HCPCS,outpatient,,,167,100.20,26,,,,,other,not separately reimbusable,77.61,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,58.26,100,,,fee schedule,100% of cigna custom fee schedule,85.37,110,,,fee schedule,110% of cms physician fee schedule,78.39,101,,,fee schedule,101% of cms physician fee schedule ,78.39,116.15,,,fee schedule,116.51% of cms physician fee schedule,78.39,101,,,fee schedule,101% of cms physician fee schedule,147.46,110,,,fee schedule,110% of humana physician fee schedule,85.37,110,,,fee schedule,110% of humana physician fee schedule,116.42,150,,,fee schedule,100% of cms fee schedule,77.61,100,,,fee schedule,100% of cms physician fee schedule,116.42,150,,,fee schedule,150% of cms physician fee schedule,77.61,150,
PF US ABDOMEN COMPLETE,36000030,CDM,972,RC,76700,HCPCS,outpatient,,,202,121.20,26,,,,,other,not separately reimbusable,105.64,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,80.24,100,,,fee schedule,100% of cigna custom fee schedule,116.2,110,,,fee schedule,110% of cms physician fee schedule,106.7,101,,,fee schedule,101% of cms physician fee schedule ,106.7,116.15,,,fee schedule,116.51% of cms physician fee schedule,106.7,101,,,fee schedule,101% of cms physician fee schedule,200.72,110,,,fee schedule,110% of humana physician fee schedule,116.2,110,,,fee schedule,110% of humana physician fee schedule,158.46,150,,,fee schedule,100% of cms fee schedule,105.64,100,,,fee schedule,100% of cms physician fee schedule,158.46,150,,,fee schedule,150% of cms physician fee schedule,100,158.46,
PF US ABD LMTD SINGLE ORGAN,36000031,CDM,972,RC,76705,HCPCS,outpatient,,,145,87.00,26,,,,,other,not separately reimbusable,78.89,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,59.93,100,,,fee schedule,100% of cigna custom fee schedule,86.78,110,,,fee schedule,110% of cms physician fee schedule,79.68,101,,,fee schedule,101% of cms physician fee schedule ,79.68,116.15,,,fee schedule,116.51% of cms physician fee schedule,79.68,101,,,fee schedule,101% of cms physician fee schedule,149.89,110,,,fee schedule,110% of humana physician fee schedule,86.78,110,,,fee schedule,110% of humana physician fee schedule,118.34,150,,,fee schedule,100% of cms fee schedule,78.89,100,,,fee schedule,100% of cms physician fee schedule,118.34,150,,,fee schedule,150% of cms physician fee schedule,78.89,150,
PF US RENAL AND BLADDER,36000032,CDM,972,RC,76770,HCPCS,outpatient,,,181,108.60,26,,,,,other,not separately reimbusable,98.27,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,74.25,100,,,fee schedule,100% of cigna custom fee schedule,108.1,110,,,fee schedule,110% of cms physician fee schedule,99.25,101,,,fee schedule,101% of cms physician fee schedule ,99.25,116.15,,,fee schedule,116.51% of cms physician fee schedule,99.25,101,,,fee schedule,101% of cms physician fee schedule,186.71,110,,,fee schedule,110% of humana physician fee schedule,108.1,110,,,fee schedule,110% of humana physician fee schedule,147.41,150,,,fee schedule,100% of cms fee schedule,98.27,100,,,fee schedule,100% of cms physician fee schedule,147.41,150,,,fee schedule,150% of cms physician fee schedule,98.27,150,
PF US PELVIC COMPLETE,36000036,CDM,972,RC,76856,HCPCS,outpatient,,,169,101.40,26,,,,,other,not separately reimbusable,95.35,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,72.32,100,,,fee schedule,100% of cigna custom fee schedule,104.89,110,,,fee schedule,110% of cms physician fee schedule,96.3,101,,,fee schedule,101% of cms physician fee schedule ,96.3,116.15,,,fee schedule,116.51% of cms physician fee schedule,96.3,101,,,fee schedule,101% of cms physician fee schedule,181.17,110,,,fee schedule,110% of humana physician fee schedule,104.89,110,,,fee schedule,110% of humana physician fee schedule,143.03,150,,,fee schedule,100% of cms fee schedule,95.35,100,,,fee schedule,100% of cms physician fee schedule,143.03,150,,,fee schedule,150% of cms physician fee schedule,95.35,150,
PF US LIMITED or Follow Up Pelvis,42002150,CDM,972,RC,76857,HCPCS,outpatient,,,122,73.20,26,,,,,other,not separately reimbusable,45.48,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,32.26,100,,,fee schedule,100% of cigna custom fee schedule,50.03,110,,,fee schedule,110% of cms physician fee schedule,45.93,101,,,fee schedule,101% of cms physician fee schedule ,45.93,116.15,,,fee schedule,116.51% of cms physician fee schedule,45.93,101,,,fee schedule,101% of cms physician fee schedule,86.41,110,,,fee schedule,110% of humana physician fee schedule,50.03,110,,,fee schedule,110% of humana physician fee schedule,68.22,150,,,fee schedule,100% of cms fee schedule,45.48,100,,,fee schedule,100% of cms physician fee schedule,68.22,150,,,fee schedule,150% of cms physician fee schedule,45.48,150,
PF US SCROTUM,36000038,CDM,972,RC,76870,HCPCS,outpatient,,,157,94.20,26,,,,,other,not separately reimbusable,90.47,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,45.44,100,,,fee schedule,100% of cigna custom fee schedule,99.52,110,,,fee schedule,110% of cms physician fee schedule,91.37,101,,,fee schedule,101% of cms physician fee schedule ,91.37,116.15,,,fee schedule,116.51% of cms physician fee schedule,91.37,101,,,fee schedule,101% of cms physician fee schedule,171.89,110,,,fee schedule,110% of humana physician fee schedule,99.52,110,,,fee schedule,110% of humana physician fee schedule,135.71,150,,,fee schedule,100% of cms fee schedule,90.47,100,,,fee schedule,100% of cms physician fee schedule,135.71,150,,,fee schedule,150% of cms physician fee schedule,90.47,150,
"PF US LIMITED,NONVASCULAR",42002075,CDM,972,RC,76882,HCPCS,outpatient,,,120,72.00,26,,,,,other,not separately reimbusable,58.69,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,24.44,100,,,fee schedule,100% of cigna custom fee schedule,64.56,110,,,fee schedule,110% of cms physician fee schedule,59.28,101,,,fee schedule,101% of cms physician fee schedule ,59.28,116.15,,,fee schedule,116.51% of cms physician fee schedule,59.28,101,,,fee schedule,101% of cms physician fee schedule,111.51,110,,,fee schedule,110% of humana physician fee schedule,64.56,110,,,fee schedule,110% of humana physician fee schedule,88.04,150,,,fee schedule,100% of cms fee schedule,58.69,100,,,fee schedule,100% of cms physician fee schedule,88.04,150,,,fee schedule,150% of cms physician fee schedule,58.69,150,
PF US EXTRACRANIAL  BILAT CAROTID,42001048,CDM,972,RC,93880,HCPCS,outpatient,,,201,120.60,26,,,,,other,not separately reimbusable,170.4,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,190.4,100,,,fee schedule,100% of cigna custom fee schedule,187.44,110,,,fee schedule,110% of cms physician fee schedule,172.1,101,,,fee schedule,101% of cms physician fee schedule ,172.1,116.15,,,fee schedule,116.51% of cms physician fee schedule,172.1,101,,,fee schedule,101% of cms physician fee schedule,323.76,110,,,fee schedule,110% of humana physician fee schedule,187.44,110,,,fee schedule,110% of humana physician fee schedule,255.6,150,,,fee schedule,100% of cms fee schedule,170.4,100,,,fee schedule,100% of cms physician fee schedule,255.6,150,,,fee schedule,150% of cms physician fee schedule,100,255.6,
PF DOPPLER VEN UNILAT,42001049,CDM,972,RC,93971,HCPCS,outpatient,,,112,67.20,26,,,,,other,not separately reimbusable,106.4,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,112.72,100,,,fee schedule,100% of cigna custom fee schedule,117.04,110,,,fee schedule,110% of cms physician fee schedule,107.46,101,,,fee schedule,101% of cms physician fee schedule ,107.46,116.15,,,fee schedule,116.51% of cms physician fee schedule,107.46,101,,,fee schedule,101% of cms physician fee schedule,202.16,110,,,fee schedule,110% of humana physician fee schedule,117.04,110,,,fee schedule,110% of humana physician fee schedule,159.6,150,,,fee schedule,100% of cms fee schedule,106.4,100,,,fee schedule,100% of cms physician fee schedule,159.6,150,,,fee schedule,150% of cms physician fee schedule,100,159.6,
PF CLAVICLE 2VIEW,42000206,CDM,972,RC,73000,HCPCS,outpatient,,,42,25.20,26,,,,,other,not separately reimbusable,29.41,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,17.99,100,,,fee schedule,100% of cigna custom fee schedule,32.35,110,,,fee schedule,110% of cms physician fee schedule,29.7,101,,,fee schedule,101% of cms physician fee schedule ,29.7,116.15,,,fee schedule,116.51% of cms physician fee schedule,29.7,101,,,fee schedule,101% of cms physician fee schedule,55.88,110,,,fee schedule,110% of humana physician fee schedule,32.35,110,,,fee schedule,110% of humana physician fee schedule,44.12,150,,,fee schedule,100% of cms fee schedule,29.41,100,,,fee schedule,100% of cms physician fee schedule,44.12,150,,,fee schedule,150% of cms physician fee schedule,29.41,150,
PF DOPPLER VENOUS COMP BILAT,42001059,CDM,972,RC,93970,HCPCS,outpatient,,,175,105.00,26,,,,,other,not separately reimbusable,167.27,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,185,100,,,fee schedule,100% of cigna custom fee schedule,184,110,,,fee schedule,110% of cms physician fee schedule,168.94,101,,,fee schedule,101% of cms physician fee schedule ,168.94,116.15,,,fee schedule,116.51% of cms physician fee schedule,168.94,101,,,fee schedule,101% of cms physician fee schedule,317.81,110,,,fee schedule,110% of humana physician fee schedule,184,110,,,fee schedule,110% of humana physician fee schedule,250.91,150,,,fee schedule,100% of cms fee schedule,167.27,100,,,fee schedule,100% of cms physician fee schedule,250.91,150,,,fee schedule,150% of cms physician fee schedule,100,250.91,
PF ART FLOW BI COMP UPR EXT w/ ABI,43509006,CDM,972,RC,93923,HCPCS,outpatient,,,113,67.80,26,,,,,other,not separately reimbusable,113,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,129.3,100,,,fee schedule,100% of cigna custom fee schedule,124.3,110,,,fee schedule,110% of cms physician fee schedule,114.13,101,,,fee schedule,101% of cms physician fee schedule ,114.13,116.15,,,fee schedule,116.51% of cms physician fee schedule,114.13,101,,,fee schedule,101% of cms physician fee schedule,214.7,110,,,fee schedule,110% of humana physician fee schedule,124.3,110,,,fee schedule,110% of humana physician fee schedule,169.5,150,,,fee schedule,100% of cms fee schedule,113,100,,,fee schedule,100% of cms physician fee schedule,169.5,150,,,fee schedule,150% of cms physician fee schedule,100,169.5,
PF CT ORB/SEL/PF/EAR W/O CNT,42003160,CDM,972,RC,70480,HCPCS,outpatient,,,319,191.40,26,,,,,other,not separately reimbusable,148.67,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,150.89,100,,,fee schedule,100% of cigna custom fee schedule,163.54,110,,,fee schedule,110% of cms physician fee schedule,150.16,101,,,fee schedule,101% of cms physician fee schedule ,150.16,116.15,,,fee schedule,116.51% of cms physician fee schedule,150.16,101,,,fee schedule,101% of cms physician fee schedule,282.47,110,,,fee schedule,110% of humana physician fee schedule,163.54,110,,,fee schedule,110% of humana physician fee schedule,223.01,150,,,fee schedule,100% of cms fee schedule,148.67,100,,,fee schedule,100% of cms physician fee schedule,223.01,150,,,fee schedule,150% of cms physician fee schedule,100,223.01,
PF DUPLEX LOWER EXT ARTERIES BILATERAL,42001062,CDM,972,RC,93925,HCPCS,outpatient,,,198,118.80,26,,,,,other,not separately reimbusable,198,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,242.24,100,,,fee schedule,100% of cigna custom fee schedule,217.8,110,,,fee schedule,110% of cms physician fee schedule,199.98,101,,,fee schedule,101% of cms physician fee schedule ,199.98,116.15,,,fee schedule,116.51% of cms physician fee schedule,199.98,101,,,fee schedule,101% of cms physician fee schedule,376.2,110,,,fee schedule,110% of humana physician fee schedule,217.8,110,,,fee schedule,110% of humana physician fee schedule,297,150,,,fee schedule,100% of cms fee schedule,198,100,,,fee schedule,100% of cms physician fee schedule,297,150,,,fee schedule,150% of cms physician fee schedule,100,297,
PF ARTERIAL DOPPLER BILATERAL UPPER EXTREMITY,42001061,CDM,972,RC,93930,HCPCS,outpatient,,,127,76.20,,,,,,other,not separately reimbusable,127,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,195.71,100,,,fee schedule,100% of cigna custom fee schedule,139.7,110,,,fee schedule,110% of cms physician fee schedule,128.27,101,,,fee schedule,101% of cms physician fee schedule ,128.27,116.15,,,fee schedule,116.51% of cms physician fee schedule,128.27,101,,,fee schedule,101% of cms physician fee schedule,241.3,110,,,fee schedule,110% of humana physician fee schedule,139.7,110,,,fee schedule,110% of humana physician fee schedule,190.5,150,,,fee schedule,100% of cms fee schedule,127,100,,,fee schedule,100% of cms physician fee schedule,190.5,150,,,fee schedule,150% of cms physician fee schedule,100,190.5,
PF ABDOMEN 2 VIEWS,42000015,CDM,972,RC,74019,HCPCS,outpatient,,,58,34.80,26,,,,,other,not separately reimbusable,33.2,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,21.76,100,,,fee schedule,100% of cigna custom fee schedule,36.52,110,,,fee schedule,110% of cms physician fee schedule,33.53,101,,,fee schedule,101% of cms physician fee schedule ,33.53,116.15,,,fee schedule,116.51% of cms physician fee schedule,33.53,101,,,fee schedule,101% of cms physician fee schedule,63.08,110,,,fee schedule,110% of humana physician fee schedule,36.52,110,,,fee schedule,110% of humana physician fee schedule,49.8,150,,,fee schedule,100% of cms fee schedule,33.2,100,,,fee schedule,100% of cms physician fee schedule,49.8,150,,,fee schedule,150% of cms physician fee schedule,33.2,150,
PF ART FLOW UNILAT UPPER EXT,42001053,CDM,972,RC,93931,HCPCS,outpatient,,,113,67.80,,,,,,other,not separately reimbusable,110.87,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,120.95,100,,,fee schedule,100% of cigna custom fee schedule,121.96,110,,,fee schedule,110% of cms physician fee schedule,111.98,101,,,fee schedule,101% of cms physician fee schedule ,111.98,116.15,,,fee schedule,116.51% of cms physician fee schedule,111.98,101,,,fee schedule,101% of cms physician fee schedule,210.65,110,,,fee schedule,110% of humana physician fee schedule,121.96,110,,,fee schedule,110% of humana physician fee schedule,166.31,150,,,fee schedule,100% of cms fee schedule,110.87,100,,,fee schedule,100% of cms physician fee schedule,166.31,150,,,fee schedule,150% of cms physician fee schedule,100,166.31,
PF BILATERAL KNEES STANDING,42000445,CDM,972,RC,73565,HCPCS,outpatient,,,45,27.00,26,,,,,other,not separately reimbusable,35.83,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,23.12,100,,,fee schedule,100% of cigna custom fee schedule,39.41,110,,,fee schedule,110% of cms physician fee schedule,36.19,101,,,fee schedule,101% of cms physician fee schedule ,36.19,116.15,,,fee schedule,116.51% of cms physician fee schedule,36.19,101,,,fee schedule,101% of cms physician fee schedule,68.08,110,,,fee schedule,110% of humana physician fee schedule,39.41,110,,,fee schedule,110% of humana physician fee schedule,53.75,150,,,fee schedule,100% of cms fee schedule,35.83,100,,,fee schedule,100% of cms physician fee schedule,53.75,150,,,fee schedule,150% of cms physician fee schedule,35.83,150,
PF CT THORACIC SPINE W/O,42003380,CDM,972,RC,72128,HCPCS,outpatient,,,256,153.60,26,,,,,other,not separately reimbusable,121.01,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,117.04,100,,,fee schedule,100% of cigna custom fee schedule,133.11,110,,,fee schedule,110% of cms physician fee schedule,122.22,101,,,fee schedule,101% of cms physician fee schedule ,122.22,116.15,,,fee schedule,116.51% of cms physician fee schedule,122.22,101,,,fee schedule,101% of cms physician fee schedule,229.92,110,,,fee schedule,110% of humana physician fee schedule,133.11,110,,,fee schedule,110% of humana physician fee schedule,181.52,150,,,fee schedule,100% of cms fee schedule,121.01,100,,,fee schedule,100% of cms physician fee schedule,181.52,150,,,fee schedule,150% of cms physician fee schedule,100,181.52,
PF SCAPULA,42000701,CDM,972,RC,73010,HCPCS,outpatient,,,47,28.20,26,,,,,other,not separately reimbusable,21.87,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,19.58,100,,,fee schedule,100% of cigna custom fee schedule,24.06,110,,,fee schedule,110% of cms physician fee schedule,22.09,101,,,fee schedule,101% of cms physician fee schedule ,22.09,116.15,,,fee schedule,116.51% of cms physician fee schedule,22.09,101,,,fee schedule,101% of cms physician fee schedule,41.55,110,,,fee schedule,110% of humana physician fee schedule,24.06,110,,,fee schedule,110% of humana physician fee schedule,32.81,150,,,fee schedule,100% of cms fee schedule,21.87,100,,,fee schedule,100% of cms physician fee schedule,32.81,150,,,fee schedule,150% of cms physician fee schedule,21.87,150,
PF CT UPPER EXT W/O CONTRAST,42004312,CDM,972,RC,73200,HCPCS,outpatient,,,256,153.60,26,,,,,other,not separately reimbusable,149.29,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,116.37,100,,,fee schedule,100% of cigna custom fee schedule,164.22,110,,,fee schedule,110% of cms physician fee schedule,150.78,101,,,fee schedule,101% of cms physician fee schedule ,150.78,116.15,,,fee schedule,116.51% of cms physician fee schedule,150.78,101,,,fee schedule,101% of cms physician fee schedule,283.65,110,,,fee schedule,110% of humana physician fee schedule,164.22,110,,,fee schedule,110% of humana physician fee schedule,223.94,150,,,fee schedule,100% of cms fee schedule,149.29,100,,,fee schedule,100% of cms physician fee schedule,223.94,150,,,fee schedule,150% of cms physician fee schedule,100,223.94,
PF ART FLOW UINILAT,42001055,CDM,972,RC,93926,HCPCS,outpatient,,,124.5,74.70,26,,,,,other,not separately reimbusable,124.5,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,142.5,100,,,fee schedule,100% of cigna custom fee schedule,136.95,110,,,fee schedule,110% of cms physician fee schedule,125.75,101,,,fee schedule,101% of cms physician fee schedule ,125.75,116.15,,,fee schedule,116.51% of cms physician fee schedule,125.75,101,,,fee schedule,101% of cms physician fee schedule,236.55,110,,,fee schedule,110% of humana physician fee schedule,136.95,110,,,fee schedule,110% of humana physician fee schedule,186.75,150,,,fee schedule,100% of cms fee schedule,124.5,100,,,fee schedule,100% of cms physician fee schedule,186.75,150,,,fee schedule,150% of cms physician fee schedule,100,186.75,
PF CALCANEOUS 2 VIEWS,42000611,CDM,972,RC,73650,HCPCS,outpatient,,,41.5,24.90,26,,,,,other,not separately reimbusable,25.91,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,17.55,100,,,fee schedule,100% of cigna custom fee schedule,28.5,110,,,fee schedule,110% of cms physician fee schedule,26.17,101,,,fee schedule,101% of cms physician fee schedule ,26.17,116.15,,,fee schedule,116.51% of cms physician fee schedule,26.17,101,,,fee schedule,101% of cms physician fee schedule,49.23,110,,,fee schedule,110% of humana physician fee schedule,28.5,110,,,fee schedule,110% of humana physician fee schedule,38.87,150,,,fee schedule,100% of cms fee schedule,25.91,100,,,fee schedule,100% of cms physician fee schedule,38.87,150,,,fee schedule,150% of cms physician fee schedule,25.91,150,
PF T-SPINE 3 VIEWS,42000785,CDM,972,RC,72072,HCPCS,outpatient,,,66,39.60,26,,,,,other,not separately reimbusable,35.82,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,22.4,100,,,fee schedule,100% of cigna custom fee schedule,39.4,110,,,fee schedule,110% of cms physician fee schedule,36.18,101,,,fee schedule,101% of cms physician fee schedule ,36.18,116.15,,,fee schedule,116.51% of cms physician fee schedule,36.18,101,,,fee schedule,101% of cms physician fee schedule,68.06,110,,,fee schedule,110% of humana physician fee schedule,39.4,110,,,fee schedule,110% of humana physician fee schedule,53.73,150,,,fee schedule,100% of cms fee schedule,35.82,100,,,fee schedule,100% of cms physician fee schedule,53.73,150,,,fee schedule,150% of cms physician fee schedule,35.82,150,
PF RIBS BILATERAL 3VIEW,42000670,CDM,972,RC,71110,HCPCS,outpatient,,,75.8,45.48,26,,,,,other,not separately reimbusable,39.86,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,24.55,100,,,fee schedule,100% of cigna custom fee schedule,43.85,110,,,fee schedule,110% of cms physician fee schedule,40.26,101,,,fee schedule,101% of cms physician fee schedule ,40.26,116.15,,,fee schedule,116.51% of cms physician fee schedule,40.26,101,,,fee schedule,101% of cms physician fee schedule,75.73,110,,,fee schedule,110% of humana physician fee schedule,43.85,110,,,fee schedule,110% of humana physician fee schedule,59.79,150,,,fee schedule,100% of cms fee schedule,39.86,100,,,fee schedule,100% of cms physician fee schedule,59.79,150,,,fee schedule,150% of cms physician fee schedule,39.86,150,
PF TRANSVAGINAL ULTRASOUND,42002230,CDM,972,RC,76830,HCPCS,outpatient,,,176.85,106.11,TC,,,,,other,not separately reimbusable,107.68,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,79.9,100,,,fee schedule,100% of cigna custom fee schedule,118.45,110,,,fee schedule,110% of cms physician fee schedule,108.76,101,,,fee schedule,101% of cms physician fee schedule ,108.76,116.15,,,fee schedule,116.51% of cms physician fee schedule,108.76,101,,,fee schedule,101% of cms physician fee schedule,204.59,110,,,fee schedule,110% of humana physician fee schedule,118.45,110,,,fee schedule,110% of humana physician fee schedule,161.52,150,,,fee schedule,100% of cms fee schedule,107.68,100,,,fee schedule,100% of cms physician fee schedule,161.52,150,,,fee schedule,150% of cms physician fee schedule,100,161.52,
PF US OB <14 WKS SINGLE,42002236,CDM,972,RC,76801,HCPCS,outpatient,,,277.95,166.77,26,,,,,other,not separately reimbusable,107.17,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,81.8,100,,,fee schedule,100% of cigna custom fee schedule,117.89,110,,,fee schedule,110% of cms physician fee schedule,108.24,101,,,fee schedule,101% of cms physician fee schedule ,108.24,116.15,,,fee schedule,116.51% of cms physician fee schedule,108.24,101,,,fee schedule,101% of cms physician fee schedule,203.62,110,,,fee schedule,110% of humana physician fee schedule,117.89,110,,,fee schedule,110% of humana physician fee schedule,160.76,150,,,fee schedule,100% of cms fee schedule,107.17,100,,,fee schedule,100% of cms physician fee schedule,160.76,150,,,fee schedule,150% of cms physician fee schedule,100,160.76,
PF TRANSVAG OBS LIMITED,42002235,CDM,972,RC,76817,HCPCS,outpatient,,,208.95,125.37,26,,,,,other,not separately reimbusable,84.51,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,64.55,100,,,fee schedule,100% of cigna custom fee schedule,92.96,110,,,fee schedule,110% of cms physician fee schedule,85.36,101,,,fee schedule,101% of cms physician fee schedule ,85.36,116.15,,,fee schedule,116.51% of cms physician fee schedule,85.36,101,,,fee schedule,101% of cms physician fee schedule,160.57,110,,,fee schedule,110% of humana physician fee schedule,92.96,110,,,fee schedule,110% of humana physician fee schedule,126.77,150,,,fee schedule,100% of cms fee schedule,84.51,100,,,fee schedule,100% of cms physician fee schedule,126.77,150,,,fee schedule,150% of cms physician fee schedule,84.51,150,
PF L-SPINE FLEX/EXT/BENDING,42000460,CDM,972,RC,72120,HCPCS,outpatient,,,61,36.60,26,,,,,other,not separately reimbusable,36.66,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,26.19,100,,,fee schedule,100% of cigna custom fee schedule,40.33,110,,,fee schedule,110% of cms physician fee schedule,37.03,101,,,fee schedule,101% of cms physician fee schedule ,37.03,116.15,,,fee schedule,116.51% of cms physician fee schedule,37.03,101,,,fee schedule,101% of cms physician fee schedule,69.65,110,,,fee schedule,110% of humana physician fee schedule,40.33,110,,,fee schedule,110% of humana physician fee schedule,54.99,150,,,fee schedule,100% of cms fee schedule,36.66,100,,,fee schedule,100% of cms physician fee schedule,54.99,150,,,fee schedule,150% of cms physician fee schedule,36.66,150,
PF SFT TISSUE NCK W CNTRS,42003340,CDM,972,RC,70491,HCPCS,outpatient,,,367.85,220.71,26,,,,,other,not separately reimbusable,171.83,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,152.81,100,,,fee schedule,100% of cigna custom fee schedule,189.01,110,,,fee schedule,110% of cms physician fee schedule,173.55,101,,,fee schedule,101% of cms physician fee schedule ,173.55,116.15,,,fee schedule,116.51% of cms physician fee schedule,173.55,101,,,fee schedule,101% of cms physician fee schedule,326.48,110,,,fee schedule,110% of humana physician fee schedule,189.01,110,,,fee schedule,110% of humana physician fee schedule,257.75,150,,,fee schedule,100% of cms fee schedule,171.83,100,,,fee schedule,100% of cms physician fee schedule,257.75,150,,,fee schedule,150% of cms physician fee schedule,100,257.75,
PF Lower ext (infant),42000476,CDM,972,RC,73592,HCPCS,outpatient,,,42,25.20,26,,,,,other,not separately reimbusable,28.54,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,17.99,100,,,fee schedule,100% of cigna custom fee schedule,31.39,110,,,fee schedule,110% of cms physician fee schedule,28.83,101,,,fee schedule,101% of cms physician fee schedule ,28.83,116.15,,,fee schedule,116.51% of cms physician fee schedule,28.83,101,,,fee schedule,101% of cms physician fee schedule,54.23,110,,,fee schedule,110% of humana physician fee schedule,31.39,110,,,fee schedule,110% of humana physician fee schedule,42.81,150,,,fee schedule,100% of cms fee schedule,28.54,100,,,fee schedule,100% of cms physician fee schedule,42.81,150,,,fee schedule,150% of cms physician fee schedule,28.54,150,
PF US AORTA ABD LIMITED,42002060,CDM,972,RC,76775,HCPCS,outpatient,,,144.8,86.88,26,,,,,other,not separately reimbusable,54.94,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,38.95,100,,,fee schedule,100% of cigna custom fee schedule,60.43,110,,,fee schedule,110% of cms physician fee schedule,55.49,101,,,fee schedule,101% of cms physician fee schedule ,55.49,116.15,,,fee schedule,116.51% of cms physician fee schedule,55.49,101,,,fee schedule,101% of cms physician fee schedule,104.39,110,,,fee schedule,110% of humana physician fee schedule,60.43,110,,,fee schedule,110% of humana physician fee schedule,82.41,150,,,fee schedule,100% of cms fee schedule,54.94,100,,,fee schedule,100% of cms physician fee schedule,82.41,150,,,fee schedule,150% of cms physician fee schedule,54.94,150,
PF CT ANGIOGRAPHY CHEST,42003002,CDM,972,RC,71275,HCPCS,outpatient,,,436.95,262.17,26,,,,,other,not separately reimbusable,261.19,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,195.08,100,,,fee schedule,100% of cigna custom fee schedule,287.31,110,,,fee schedule,110% of cms physician fee schedule,263.8,101,,,fee schedule,101% of cms physician fee schedule ,263.8,116.15,,,fee schedule,116.51% of cms physician fee schedule,263.8,101,,,fee schedule,101% of cms physician fee schedule,496.26,110,,,fee schedule,110% of humana physician fee schedule,287.31,110,,,fee schedule,110% of humana physician fee schedule,391.79,150,,,fee schedule,100% of cms fee schedule,261.19,100,,,fee schedule,100% of cms physician fee schedule,391.79,150,,,fee schedule,150% of cms physician fee schedule,100,391.79,
PF STERNUM 2 VIEWS,42000775,CDM,972,RC,71120,HCPCS,outpatient,,,47.45,28.47,26,,,,,other,not separately reimbusable,30.45,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,19.22,100,,,fee schedule,100% of cigna custom fee schedule,33.5,110,,,fee schedule,110% of cms physician fee schedule,30.75,101,,,fee schedule,101% of cms physician fee schedule ,30.75,116.15,,,fee schedule,116.51% of cms physician fee schedule,30.75,101,,,fee schedule,101% of cms physician fee schedule,57.86,110,,,fee schedule,110% of humana physician fee schedule,33.5,110,,,fee schedule,110% of humana physician fee schedule,45.68,150,,,fee schedule,100% of cms fee schedule,30.45,100,,,fee schedule,100% of cms physician fee schedule,45.68,150,,,fee schedule,150% of cms physician fee schedule,30.45,150,
PF RIBS UNILAT W/ 1V CHEST 3+ VIEWS,42000681,CDM,972,RC,71101,HCPCS,outpatient,,,45,27.00,26,,,,,other,not separately reimbusable,38.32,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,23.96,100,,,fee schedule,100% of cigna custom fee schedule,42.15,110,,,fee schedule,110% of cms physician fee schedule,38.7,101,,,fee schedule,101% of cms physician fee schedule ,38.7,116.15,,,fee schedule,116.51% of cms physician fee schedule,38.7,101,,,fee schedule,101% of cms physician fee schedule,72.81,110,,,fee schedule,110% of humana physician fee schedule,42.15,110,,,fee schedule,110% of humana physician fee schedule,57.48,150,,,fee schedule,100% of cms fee schedule,38.32,100,,,fee schedule,100% of cms physician fee schedule,57.48,150,,,fee schedule,150% of cms physician fee schedule,38.32,150,
PF SCOLIOSIS SERIES 4-5 VIEWS,42001077,CDM,972,RC,72083,HCPCS,outpatient,,,53,31.80,26,,,,,other,not separately reimbusable,53,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,43.79,100,,,fee schedule,100% of cigna custom fee schedule,58.3,110,,,fee schedule,110% of cms physician fee schedule,53.53,101,,,fee schedule,101% of cms physician fee schedule ,53.53,116.15,,,fee schedule,116.51% of cms physician fee schedule,53.53,101,,,fee schedule,101% of cms physician fee schedule,100.7,110,,,fee schedule,110% of humana physician fee schedule,58.3,110,,,fee schedule,110% of humana physician fee schedule,79.5,150,,,fee schedule,100% of cms fee schedule,53,100,,,fee schedule,100% of cms physician fee schedule,79.5,150,,,fee schedule,150% of cms physician fee schedule,53,150,
PF ENTIRE SPINE 1 VIEW,42001075,CDM,972,RC,72081,HCPCS,outpatient,,,39,23.40,26,,,,,other,not separately reimbusable,38.57,100,,,fee schedule,100% of cms physician fee schedule,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,,,,,other,not separately reimbusable,25.49,100,,,fee schedule,100% of cigna custom fee schedule,42.43,110,,,fee schedule,110% of cms physician fee schedule,38.96,101,,,fee schedule,101% of cms physician fee schedule ,38.96,116.15,,,fee schedule,116.51% of cms physician fee schedule,38.96,101,,,fee schedule,101% of cms physician fee schedule,73.28,110,,,fee schedule,110% of humana physician fee schedule,42.43,110,,,fee schedule,110% of humana physician fee schedule,57.86,150,,,fee schedule,100% of cms fee schedule,38.57,100,,,fee schedule,100% of cms physician fee schedule,57.86,150,,,fee schedule,150% of cms physician fee schedule,38.57,150,
CHRONIC CARE MANAGMENT 20 MIN PER MONTH,43601498,CDM,521,RC,G0511,HCPCS,outpatient,,,75,45.00,,45,60,,36,percent of total billed charges,60% of total billed charges,36,48,,28.8,percent of total billed charges,48% of total billed charges,37.5,50,,30,percent of total billed charges,50% of total billed charges,37.5,50,,30,percent of total billed charges,50% of total billed charges,37.5,50,,30,percent of total billed charges,50% of total billed charges,,,,,other,not separately reimbusable,52.5,70,,42,percent of total billed charges,70% of total billed charges,36.36,48.48,,29.088,percent of total billed charges,48.48% of total billed charges,49.21,116.15,,,fee schedule,116.51% of cms physician fee schedule,36.36,48.48,,29.088,percent of total billed charges,48.48% of total billed charges,52.5,70,,42,percent of total billed charges,70% of total billed charges,52.5,70,,42,percent of total billed charges,70% of total billed charges,,,,,other,not separately reimbusable,36.36,48.48,,29.088,percent of total billed charges,48.48% of total billed charges,67.5,90,,54,percent of total billed charges,90% of total billed charges,36.36,90,